National Alliance on Mental Illness
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The Proposed DSM-5: Alterations and Altercations
By Doug Bradley, NAMI HelpLine Coordinator
One of the biggest stories in mental health over the past few years has been the proposed revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM). As the main guide used by psychiatrists, psychologists, and social workers in the U.S. to diagnose mental illness, the DSM is an important factor in our mental health system. The manual often influences what type of care people get (or should get), how practitioners are reimbursed, and how people diagnosed with mental illness view themselves and their recoveries.
While the DSM-5 has not been finalized, there are several big changes from the last manual (DSM-IV) starting with the title. The American Psychiatric Association (APA) used roman numerals (i.e., I, II, III) on previous editions but will now use Arabic numbers (i.e., 1,2,3) for two reasons. Firstly, Arabic numbers are more universally recognized. Secondly, updates to the manual will be easier to track. Prior changes were denoted by abbreviations such as –R or –TR, which did not indicate which came first. New updates will be denoted DSM-5.1, DSM-5.2, etc., to clearly show which version is latest.
Another noticeable change is the lack of axes (e.g., Axis I for mood, anxiety and thought disorders; Axis II for personality disorders) to classify illnesses. The DSM-5 work groups felt that there was no scientific basis for this separation and abandoned the axis system for this version.
Instead, an attempt has been made to group similar disorders into 20 categories. However, there have been changes to the familiar DSM-IV groupings. The former “Mood Disorders” chapter is now divided into two sections: “Depressive Disorders” and “Bipolar and Related Disorders.” A brand-new category is “Obsessive-Compulsive and Related Disorders” which includes OCD, hoarding, compulsive hair-pulling, Body Dysmorphic Disorder and others. While all these disorders can cause anxiety, their main distinguishing features are repetitive thoughts and behavior. Also, as the treatment for them is often different than for other anxiety conditions, they have been separated from Anxiety Disorders , which in DSM-5 still contains Panic Disorder, Generalized Anxiety Disorder, etc.
Some other changes are elimination of Aspergers as a separate disorder and merging it into Autism Spectrum Disorder (ASD). The section on Personality Disorders has changed with new criteria for some and the elimination of Schizoid, Paranoid, Histrionic and Dependant Personality Disorders. Researchers feel that people in these categories rarely needed professional help and that many of their symptoms could be better described by the remaining personality disorders. Also, two controversial diagnoses (Attenuated Psychosis and Mixed Anxiety-Depression) have been kept but are in a section for topics needing further study.
As people following the creation of DSM-5 know, this process has been more contentious than past revisions. Opponents of the new manual feel that thresholds for the diagnosis of many disorders have been lowered and many people whose behavior is not currently considered “disordered” will now be labeled as ill. For example, some fear that the removal of the “grief exclusion” from Major Depressive Disorder will cause a normal and necessary part of life to be treated as a sickness. The APA has tried to address this issue by adding a note to the proposed criteria for depression clarifying that while grief itself is not a disorder, grief and depression can co-occur. Since this difference is not noted explicitly in the criteria, however, some feel that practitioners may overlook the distinction.
On the other hand, the new definition of ASD may result in fewer diagnoses. This possibility concerns some who feel that children may lose their ASD diagnosis, ending their eligibility for public programs that their parents have found useful, if not invaluable, for their children’s development.
Critics also claim that researchers have not done all the testing needed to validate the new criteria, perhaps to meet deadlines in the development of DSM-5. The APA counters that more field work and validity testing have been done for this revision than for any in the past. It also claims that there has been more input, partly thanks to the internet, from many mental health professionals and the public. Opponents say that while the APA has accepted much input, it has disregarded most from outside the association.
How will the new DSM affect the practice of psychiatry and people living with mental illness? Will it change who is considered to be living with mental illness? The maddeningly vague answer is that we will only know after DSM-5 is released in 2013. The intent of the authors of the manual, and the hope of everyone touched by mental illness, is that the new DSM will produce more accurate diagnoses leading to better treatment. The fear is that many normal behaviors will be considered symptoms of illnesses resulting in unnecessary labeling and intervention. Ideally, DSM-5 will make for better diagnoses, allowing practitioners to identify and treat mental illness before it shatters people’s lives, yet without wrongly labeling others. It’s a tall order but, at the very least, both sides in this debate will have learned much on how well this process has worked and how it can be improved in the future.