Controversy Swirls as Psychiatry Manual Gets an Update

For the first time since 1994, the American Psychiatric Association (APA) has approved a revision to its primary guide, the Diagnostic and Statistical Manual of Mental Disorders (DSM).

It’s the fifth edition of the manual, dubbed DSM-5, which is like the dictionary of mental disorders. Its definitions are the foundation of how mental disorders are treated — and how and whether that treatment gets compensated by insurance companies. The book’s formal release is in May.

We wrote about how the new DSM is likely to address substance abuse in our blog earlier this year. As described on, more than 160 clinicians and researchers worked on the DSM-5, assisted by hundreds of other clinical investigators and thousands of comments from health professionals and the general public.

Significant changes since DSM-4 include an end to the system of “axes,” which classify diagnoses into broad groups. Instead, diagnostic groups will be restructured so that disorders believed to be biologically related fall under the same headings. There’s also now a measure to indicate the severity of symptom.

If that seems rather science-y-that is, something that might make you ask, How does this affect me?-well, NPR has some ideas how theory will filter down into practice. There’s always controversy when the DSM is revised, and the DSM-5, NPR says, is the most controversial edition of all.

Until May, there’s only speculation about the exact nature of its changes. But, according to NPR, these are likely to be among them:

  • Elimination of Asperger’s Syndrome. It’s a popular diagnosis often used by mental health professionals to identify people with mild autism. Instead, look for a spectrum of autism, and people who would once have been diagnosed with Asperger’s will instead be diagnosed as mildly autistic. Many people with Asperger’s syndrome oppose this change.

    As posted on MedPage Today, a statement from the chief science officer for Autism Speaks said the group remained “concerned about the impact of the new DSM-5 criteria when they are used in real world settings. The field trials are somewhat reassuring that the criteria are working well, but these trials are based on a relatively small number of children. We still have very little information about the impact of the DSM-5 on diagnosis of autism spectrum disorder in young children and adults.”

    The group is concerned that autistic kids might be classified out of that diagnosis to a lesser one. As the statement continued, “We want to make sure that no one is excluded from obtaining a diagnosis and accessing services who needs them.”

    As explained on NPR, if the disruptive behavior of a child is deemed to be a disorder – like attention deficit hyperactivity disorder (ADHD) or autism – schools pitch in with subsidized services. If not, kids can be seen simply as troublemakers, and can be penalized for behavior they might not be able to help.

  • Advent of a new childhood disorder called disruptive mood dysregulation disorder. This proposal is the result of many clinicians believing that too many children were being categorized as having bipolar disorder and prescribed anti-psychotic drugs. The hope is that the new diagnosis will mean fewer kids are overdrugged and that diagnoses of bipolar diminish.
  • Revision of the concept of bereavement. DSM-4 warned psychiatrists away from diagnosing major depression in people who had recently suffered the death of a loved one because grief in the face of loss was seen as a normal – not abnormal – response. Such a response is not illness, but an appropriate human experience. But telling psychiatrists that people who are grieving shouldn’t be diagnosed as depressive, as one expert said, “excludes a bereaved person from being diagnosed with depression, if they have a depression, and no one wants to do that, either.”

    If it seems like hair-splitting, NPR suggests that there’s a broader lesson: the expansion of behaviors considered abnormal, such as when shyness becomes “social phobia,” and restlessness becomes ADHD.

Such is the torturous terrain of the human mind. As Dr. Roger Peele, secretary of the APA observed on NPR, “It’s important that people not see the DSM as a bible, that they respect it but don’t worship it.”

The researchers, Peele said, worked hard to make the manual as good as they could figure, but its wisdom is really just their best guesses about how to think about mental disorders and, by extension, treat them.

The New York Times’ Benedict Cary wrote an excellent piece this week summarizing the various controversies surrounding the new DSM and how they were worked out.

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