DSM-5: The Good, the Bad, the Ugly
by Donna Koger, 8.2.13
The fifth edition of the American Psychiatric Association’s manual of mental disorders is finally out, offering the latest revision in nearly 20 years of the diagnostic bible used by individuals and agencies, insurers, schools and government bodies to navigate the behavioral health landscape.
But just as it’s released, the new Diagnostic and Statistical Manual of Mental Health Disorders — widely known as the DSM-5 — is under attack by prominent critics, including the chairman of the task force that created the last version. So here is the Good, Bad, and Ugly of the DSM-5:
“The changes to the manual will help clinicians more precisely identify mental disorders and improve diagnosis while maintaining the continuity of care,” said Dr. David J. Kupfer, chair of the DSM-5 task force, in a statement. “We expect these changes to help clinicians better serve patients and to deepen our understanding of these disorders based on new research.”
In the revised, fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), “hoarding disorder” becomes a separate diagnosis, characterized by a “persistent difficulty discarding or parting with possessions, regardless of their actual value.”
The revised diagnosis should “result in more people having access to treatment,” says Randy Frost, a professor of psychology at Smith College who specializes in hoarding issues. “Right now, there are very few clinicians who know how to treat it. Once it shows up in the DSM, there will be much more pressure on clinicians to learn how to treat this problem.”
Hoarding isn’t just a messy garage or packed closet. According to the APA, it’s defined by its harmful effects — emotional, physical, social, financial and even legal — both on the hoarder and the hoarder’s family members.
Hoarding is “a disorder that involves the living areas of the home being so cluttered they can’t be used for their intended purpose,” says Frost, co-author of Stuff: Compulsive Hoarding and the Meaning of Things.
Dr. Thomas Insel, director of the National Institute for Mental Health, declared that the DSM-5 lacked “validity” because its diagnoses lack objective standards and measures.
Dr. Allen Frances, who led efforts on the DSM-IV, minces no words in describing the new 1,000-page monster that’s part guide, part dictionary for theorists and practitioners alike. “My advice for people is not to buy the DSM-5, not to use it, not to teach it,” Frances told NBC News. “I do not think it will be useful for those endeavors.”
Frances and other critics say the new manual too often turns normal reactions to life events into diagnosable mental conditions, and he suggests that doctors and everyone else use the International Classification of Diseases (ICD) instead. Since ICD is mandatory by HIPAA for billing, it makes sense to avoid confusion between providers and billers and simply use the ICD codes for all diagnoses.
Grief is one of several examples, said Frances, who has written a book about his objections called “Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life.”
“It staggers the imagination!” he said. “In two weeks after the loss of a person you love, if you are still feeling these symptoms: loss of interest, reduced appetite, trouble sleeping, less energy, it qualifies as major depressive disorder. Now it becomes a target of a drug company.”
Thanks to DSM-5, Frances said, a drug company representative could go to primary care doctors – who do the majority of psychotropic drug prescribing in the United States — and market an anti-depressant based on this new DSM criteria and not be illegally marketing the drug off-label.
“This is the legalized conversion of a sacred ritual and an inherent part of being a mammal – mourning — and turning it into a mental disorder,” he said.
Others have criticized the new guide for turning extreme childhood temper tantrums into a diagnosable condition — “disruptive mood dysregulation disorder” — while removing Asperger’s disorder as a separate diagnosis, folding it into the overall “autism spectrum disorder.”
The APA strongly disagrees with Frances’ criticisms. Dr. Jeffrey Lieberman, APA’s president-elect and the chair of the department of psychiatry at Columbia University, said personal slights and self-interest are part of the motivation behind Frances’ position.
Leaders of DSM-5 “treated him disrespectfully” Lieberman said, “and it provoked him.” Attacking DSM-5 gives Frances a “new platform to become the savior of normal – that’s his book — saving society from those irresponsible psychiatrists and the DSM,” he added.
Medical diagnoses of all kinds have expanded over the last 100 years as science gained new knowledge, Lieberman argued, pointing out that in the 1800s, there were only two mental health diagnoses: idiocy and insanity. The new volume recognizes those advances.
Arthur Caplan, the director of medical ethics at New York University’s Langone Medical Center, and a frequent contributor to NBC News, believes the controversy over new DSM criteria is misplaced.
According to Gail Saltz, a psychiatrist, psychotherapist and TODAY Show contributor, the problem isn’t with the new manual, but with a culture that demands a quick fix, making it easy for general practitioners, who may not see the same patient week after week, to misdiagnose. That can lead to over-diagnosis and, worse, overtreatment. What matters isn’t necessarily what the DSM says, but “are your symptoms impairing your functioning?” she explained.
As a mental health professional, you have the daunting task of not only correctly diagnosing your client, but also providing the right balance of treatment, offering medications where they are needed but offering other tools where they’re not.