DSM-V: hope and controversy

The draft DSM-V will be released tomorrow, 10 Feb 2010. Its website, DSM5.org (which launches tomorrow) will include proposed revisions and draft diagnostic criteria. The final version of the DSM-V is scheduled for release in May 2013.

The new edition is generating a lot of discussion, which is A Good Thing. The significant levels of unrest in the mental health field are because the DSM is seen to at least partly control the psychiatric diagnosis process, which in turn regulates treatment (pharma and non-pharma), as well as insurance pay-outs and allowances for psych care items.

The APA is framing the new edition as nothing short of revolutionary and at the same time, as usual, it runs an extremely tight ship regarding input and output. There have been calls for greater transparency into the process of creating the DSM-V, including from Dr. Allen Frances, the head of the APA taskforce that produced the last edition of the DSM.

Some of the problems that Dr. Frances has with DSM-V production process and taskforce are:

1. The very idea of a “paradigm shift” in the new edition. Psychiatric diagnosis is still descriptive, pretty much. Even as we have seen great advances in neuroscience, molecular biology, and brain imaging since the release of the last DSM edition, causality has not been proved to a level where biological tests can be a part of the DSM, and the findings of neuroscientific research are not yet suitable for clinical practice, and won’t be for quite a while.

2. The creation of new instruments, which is slow and resource-intensive, was not necessary.

3. Indirect involvement of pharma companies. To promote drug sales, pharma companies may sponsor selective “education” campaigns focusing on the diagnostic changes that increase the rate of diagnosis for disorders that will lead to the increased writing of prescriptions.

4. The inclusion of many new categories to capture subthreshold versions of disorders (for example, “pre-psychotic”, for those considered at risk for developing psychotic disorders). The intended purpose is to reduce the occurrence of false negatives (missed cases), hence boosting early detection and preventive treatment. However, this could also have the negative consequence of increasing false positives and, in Dr. Frances’s words, the “wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatments.” (Eeek!)

5. Ditto for a new series of behavioural addictions (to sex, the internet, etc.) which may cause a medicalisation of behavioural problems.

6. A failure to specify the level of empirical support needed to approve any changes to the information contained in the previous edition.

7. A lack of openness to constructive criticism.

These are all very important concerns and I’d like to see the APA address them – especially no. 4, 5 and 6. Regarding no. 7, the APA is inviting feedback and opinions on the draft, and the fact that the release date is more than 3 years from now could mean that they will have the time to consider suggestions and criticism received.

My own thinking on the DSM is that it’s not perfect, and it should not be a “bible” for psychiatry and psychology. No psych*ist I know only uses the DSM for diagnosis. It’s a tool to be used by qualified and experienced clinicians in conjunction with a thorough interview and history-taking. However, indirect influences such as selective education could play a part in even the most thorough diagnostic process.

Also, many instruments are based on DSM criteria, so while the DSM itself may not be specifically used for diagnosis or for research, it has a wide reach.

I see disorders as cultural constructs. By this I don’t mean to imply that they are “made up”, or that their effects are not extremely serious, but that a certain grouping of symptoms into a coherent disorder is arrived at in a culturally-grounded way. I don’t think there will ever be conclusive scientific proof that shows that a certain cluster of symptoms should always be grouped together to form a certain disorder (not that scientific research is not culturally-grounded and -driven itself). This can be seen in the significant changes that DSM disorders have gone through from one edition of the DSM to the next. Then, even symptoms can vary culturally. For example, in certain Middle Eastern populations mood disorders present more somatic symptoms than in Western populations. And then you have culture-bound syndromes as well.

I think it’s important to keep disorders (and symptoms) -as-constructs in mind when looking at DSM debates; however, since the biomedical model of illness, including mental illness, requires the clinician to draw a line – what does and doesn’t require treatment, what requires one particular treatment or another, a particular intervention, a particular dosage, what is and isn’t relevant in a court of law, what is and isn’t worthy of compensation, awareness of disorders as cultural constructs may not be very useful in a practical clinical way.

However – I think one of the biggest steps forward that the DSM has made over time, which gives heed to the idea of subjectivity of classification and diagnosis, is the fact that many disorders in the DSM have as one of their inclusion/exclusion criteria the degree of impairment (physical, psychological, social) that the symptoms are causing the individual. In other words, even considering the subclinical categories which will be introduced in DSM-V, one of the determining factors for treatment will still be the answer to the question: “how affected by these symptoms is your life?”. After all, unpleasant or painful symptoms that affect quality of life don’t need to be part of some greater and well-defined disorder, nor do they need to be universal in manifestation, to be taken seriously and treated in other branches of healthcare, so I don’t see why they should be disregarded in mental health. Of course, it’s also of utmost importance to heed Dr. Frances’s warnings of overmedication and overpathologisation.

Overall, I’m both excited and anxious about DSM-V and I will be taking the time to go through the information on DSM5.org tomorrow.

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