DSM-5 Debate: Committee Backs Off Some Changes, Re-Opens Comments
By Maia Szalavitz Time Magazine May 3, 2012
The committee responsible for revising the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders – psychiatry’s diagnostic “bible” commonly referred to as the DSM – has dropped the inclusion of two controversial new diagnoses that it had previously proposed, and re-opened its website for public comment on other potential revisions.
The moves are a sign that the public uproar over some of the changes has hit home, but many of the most contentious amendments still remain.
“For the first time in its history, DSM-5 has shown some flexibility and capacity to correct itself. Hopefully, this is just the beginning of what will turn out to be a number of other necessary DSM-5 retreats,”wrote Dr. Allen Frances, chair of the DSM-4 task force, on his blog at Psychology Today, in response to the committee’s turnabout. Frances is a major critic of the DSM-5.
The DSM defines and classifies all mental illnesses and is widely used by practitioners and insurance companies to determine what conditions are considered abnormal, which treatments should be covered by insurance companies, and which warrant special educational services. Consequently, changes to the precise content of the DSM have major social implications.
One of the new diagnoses that the editors chose to exclude is “attenuated psychosis syndrome,” a condition designated to describe youth who are at high risk of developing schizophrenia – before they develop the full-fledged disorder.
Problem is that only 8% of those categorized as “high risk” because they having close relatives with the disorder or have suggestive symptoms actually went on to develop schizophrenia, according to a recent study. Many critics of the new diagnosis feared that it would legitimize the potentially dangerous practice of administering powerful antipsychotic drugs to youths. With every major manufacturer of antipsychotics already paying out hundreds of millions or billions of dollars in fines for mismarketing these medications to youth and the elderly, the problem of overprescribing is already rampant – particularly in vulnerable populations like foster care children.
Frances wrote: The world is a safer place now that ‘Psychosis Risk’ will not be in DSM-5. Its rejection saves our kids from the risk of unnecessary exposure to antipsychotic drugs (with their side effects of obesity, diabetes, cardiovascular problems, and shortened life expectancy). ‘Psychosis Risk’ was the single worst DSM-5 proposal – we should all be grateful that DSM-5 has finally come to its senses in dropping it.
The committee also dropped a new diagnosis called “mixed anxiety depressive disorder,” an unnecessary designation that could have further encouraged prescription of medications. (It also made for a seriously unfortunate acronym.)
But other major controversies remain unaddressed. Although some language was changed, the committee still seems determined to include bereavement in the definition of depression, which could allow someone who is going through normal grief after a loss to be diagnosed with major depression. In previous editions of the DSM, bereavement was excluded from the definition: depressive symptoms during grieving were not considered abnormal if they were better explained by the person’s loss and were not extremely prolonged.
Another change that remains is the elimination of the diagnosis of Asperger’s syndrome, which will be subsumed under autism spectrum disorders in the DSM-5. Autism advocates oppose the change because they are concerned that families affected by Asperger’s will lose critical educational and other services. They also contend that the revision will diminish clarity of diagnoses, both for research purposes and personal understanding.
Further, the committee kept the provision to collapse two currently separate diagnoses, “substance abuse” and “substance dependence,” into “substance use disorder,” which will have varying levels of severity. While most leading addiction experts support doing away with the stigmatizing term “abuse” and the confusing term “dependence” (after all, simply being dependent on a drug to function does not define addiction), combining them into one disorder poses other problems.
Most people who have been diagnosed with substance abuse – misusing alcohol or other drugs – never go on to develop full-blown addiction and can learn moderation. However, the new definition would classify them as having “mild substance use disorder,” which would imply that they are already addicted and require abstinence-only treatment. Such a diagnosis could deter many young people from seeking help for problems like binge drinking, for example, and labeling those who do seek help as “addicts” could lead to a self-fulfilling prophecy.
The public is invited to make comments on these and other changes on the DSM-5 website from now until June 15. The new edition is still slated for publication in May 2013.
“The comments we have received over the past two years have helped sharpen our focus, not only on the strongest research and clinical evidence to support DSM-5 criteria but on the real-world implications of these changes,” American Psychiatric Association President Dr. John Oldham said in a statement. “We appreciate the public’s interest and continued participation in the DSM-5 development process.