DSM-V: Change We Can Believe In?

By Neuroskeptic | February 16, 2010 10:25 am

So the draft of DSM-V is out.

If, as everyone says, the Diagnostic and Statistical Manual is the Bible of Psychiatry, I’m not sure why it gets heavily edited once every ten years or so. Perhaps the previous versions are a kind of Old Testament, and only the current one represents the New Revelation from the gods of the mind?

Mind Hacks has an excellent summary of the proposed changes. Bear in mind that the book won’t be released until 2013. Some of the headlines:

  • Asperger’s Syndrome is out - everyone’s going to have an “autistic spectrum disorder” now.
  • Personality Disorders are out – kind of. In their place, there’s 5 Personality Disorder Types, each of which you can have to varying degrees, and also 6 Personality Traits, each of which you can have to varying degrees.
  • Hypoactive Sexual Desire Disorder – the disease which failed-antidepressant-turned-aphrodisiac flibanserin is supposed to treat – is out, to be replaced by Sexual Interest and Arousal Disorder.
  • Binge Eating Disorder, Hypersexuality Disorder, and Gambling Addiction are in. Having Fun is not a disorder yet, but that’s on the agenda for DSM-VI.

More important, at least in theory, are the Structural, Cross-Cutting, and General Classification Issues. This is where the grand changes to the whole diagnostic approach happen. But it turns out they’re pretty modest. First up, the Axis system, by which most disorders were “Axis I”, personality disorders which were “Axis II”, and other medical illnesses “Axis III”, is to be abolished – everything will be on a single Axis from now on. This will have little, if any, practical effect, but will presumably make it easier on whoever it is that has to draw up the contents page of the book.

Excitingly, “dimensional assessments” have been added… but only in a limited way. Some people have long argued that having categorical diagnoses – “schizophrenia”, “bipolar disorder”, “major depression” etc. – is a mistake, since it forces psychiatrists to pigeon-hole people, and that we should stop thinking in terms of diagnoses and just focus on symptoms: if someone’s depressed, say, then treat them for depression, but don’t diagnose them with “major depressive disorder”.

DSM-V hasn’t gone this far – the categorical diagnoses remain in most cases (the exception is Personality Disorders, see above). However, new dimensional assessments have been proposed, which are intended to complement the diagnoses, and some of them will be “cross-cutting” i.e. not tied to one particular diagnosis. See for example here for a cross-cutting questionnaire designed to assess common anxiety, depression and substance abuse symptoms.

Finally, the concept of “mental disorder” is being redefined. In DSM-V a mental disorder is (drumroll)…

A. A behavioral or psychological syndrome or pattern that occurs in an individual

B. The consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning)

C. Must not be merely an expectable response to common stressors and losses…

D. That reflects an underlying psychobiological dysfunction

E. That is not primarily a result of social deviance or conflicts with society

The main change here is that now it’s all about “psychobiological dysfunction”, whereas in DSM-IV, it was about “behavioral, psychological, or biological dysfunction”. Hmm. I am not sure what this means, if anything.

But read on, and we find something rather remarkable…

J. When considering whether to add a mental/psychiatric condition to the nomenclature, or delete a mental/psychiatric condition from the nomenclature, potential benefits (for example, provide better patient care, stimulate new research) should outweigh potential harms (for example, hurt particular individuals, be subject to misuse)

This all sounds very nice and sensible. Diagnoses should be helpful, not harmful, right?

No. Diagnoses should be true. The whole point of the DSM is that it’s supposed to be an accurate list of the mental diseases that people can suffer from. The diagnoses are in there because they are, in some sense, real, objectively-existing disorders, or at least because the American Psychiatric Association thinks that they are.

This seemingly-innocuous paragraph seems to be an admission that, in fact, disorders are added or subtracted for reasons which have little to do with whether they really, objectively exist or not. This is what’s apparently happened in the case of Temper Dysregulation Disorder with Dysphoria (TDDD), a new childhood disorder.

TDDD has been proposed in order to reduce the number of children being diagnosed with pediatric bipolar disorder. The LA Times quote a psychiatrist on the DSM-V team:

The diagnosis of bipolar [in children] “is being given, we believe, too frequently,” said Dr. David Shaffer, a member of the work group on disorders in childhood and adolescence. In reality, when such children are tracked into adulthood, very few of them turn out to be bipolar, he said.

And the DSM-V website has a lengthy rationale for TDDD, to the same effect.

Now, many people agree that pediatric bipolar is being over-diagnosed. As I’ve written before, pediatric bipolar was considered to be a vanishingly rare disease until about 10 years ago, it still is pretty much everywhere outside the USA.

So we can all sympathize with the sentiment behind TDDD – but this is fighting fire with fire. Is the only way to stop kids getting one diagnosis, to give them another one? Should we really be creating diagnoses for more or less “strategic” purposes? When the time comes for DSM-VI, and the fashion for “pediatric bipolar” has receded, will TDDD get deleted as no longer necessary? What will happen to all the “TDDD” kids then?

Can’t we just decide to diagnose people less? Apparently, that would be a rather too radical change…

CATEGORIZED UNDER: autism, books, mental health, science
  • http://www.blogger.com/profile/13351209522681966230 Mariana Soffer

    I completelly agree that the hard labelling of diseases is conterproductive, in a post I just did I also say that:”One of the main mistakes made by contemporary psychiatric practices may be encouraging patients to alleviate their afflictions just by taking medication; not by having a holistic approach that might also include a change in lifestyle, playing sports and the practice of meditation.”
    http://singyourownlullaby.blogspot.com/2010/02/psychiatry-today.html

    Which implies that having less hard labels and being more flexible in the diagnosis will work better.

  • dearieme

    Was ever a witch-doctory so carefully documented?

  • http://www.blogger.com/profile/08897374407990627879 Tardigrade

    “Can't we just decide to diagnose people less? Apparently, that would be a rather too radical change… “

    A person posted on a discussion board recently that they need to be diagnosed with something for the insurance to cover the counseling sessions.

    So apparently, no. Because the insurance organizations will cover preventative checkups and mistaken worries for physical medicine, but not for psychological medicine.

  • http://www.blogger.com/profile/04355192756373712092 Art

    “Diagnoses should be true.”

    Well then, why don't you just hurry up and discover some biomarkers that can reliably be used to make diagnoses :) If all you got is a set of symptoms, then aren't you reduced to just making educated guesses?

    For me, the interesting question is how much diagnoses actually interfere with developing the understanding of underlying biology by introducing too much heterogeneity in clinical samples. What would recruitment look like if we didn't have DSM?

  • Roger Bigod

    Leaving aside the most important factor (money), are there benefits or harms to the patient from giving something a name? Some people seem to appreciate having a name for a condition. Other times, an eponym is much easier to deal with than the well-understood popular name (Hansen's, Downs). There's also the battle in the media over whether to do away with Asperger's Syndrome. A diagnosis of autism creates expectations that are in some sense stigmatizing. The image of Asperger's is that it's less severe and can have compensating strengths. Why do the authorities want to take that away? It's not like the DSM is otherwise the epitome of clarity, precision and intellectual integrity which would be flawed by one shaky distinction.

  • http://www.blogger.com/profile/07415199338332642534 jim

    The Bible could do with a heavy edit every ten years for some time, couldn't it? Maybe the DSM committee has a better model.

    Back on topic: Pioneering genetic studies suggest that mental afflictions like schizophrenia (1) are significantly genetic, and (2) are composite conditions of maybe a few thousand alleles on a hundred or two gene loci. On top of the genes, nurture may moderate the problem or induce an acute disease. This suggests that we aren't over-diagnosing but, rather, radically under-diagnosing mental conditions.

    AFAIKS the DSM is actually aggregating large numbers of organic conditions down to broad categories based on behavioural symptoms. This sounds primitive to me. In medicine, there isn't a single treatment for a pain in the guts, we attempt to investigate the underlying organic condition to determine the appropriate treatment. Psychiatry suffers from the pre-medical problem of needing an explanation for a distressing affliction but not having a comprehensive theory of the underlying biology so reaching around for any apparently handy concepts; just like ascribing bacterial infection to miasmas. It isn't a failure of classification, it's a failure of knowledge.

    Suppose that a particular type disturbing hallucination were due could be traced back to either a defective version of a particular neurotransmitter receptor or a developmental failure where one type of nerve failed to connect correctly to a different set in some brain area. (I know, this type of explanation isn't currently possible, but it probably will be before too long.) It is likely that the best therapy options – chemical, psychological, occupational, etc – may be quite different in these cases even though the reported symptoms are actually quite similar.

    Currently, psychiatry is more-or-less confounded by the problems it has to deal with. There are some good treatments but they've been found by trial-and-error not from a comprehensive theoretical base. Luckily the situation is improving. Genotyping the DSM is a part of that.

  • Anonymous

    You do seem to be misperceiving the point of the DSM, which is to ensure that everybody who walks in to a psychiatrist's office saying “What's wrong with me?” can have an answer that can be written on a form to justify payment by a health fund.

  • Wondering

    Granted, I have not read the full newspaper article, but it's hard to take the genetics of psychiatry seriously when you read statements like this:

    The study was conducted with several other institutions, including the National Institute of Mental Health. It involved 220 participants, 130 of whom had been diagnosed with SAD and 90 participants with no history of mental illness.

    Using a genetics test, the study authors found that seven of the 220 participants carried two copies of the mutation that may be a factor in causing SAD, and, strikingly, all seven belonged to the SAD group.

    (Emphasis mine).

    Now, what are the odds? Admittedly, they write later on that

    The researchers found that a person with two copies of the gene is five times more likely to have symptoms of SAD than a person without the mutation.

    So to summarize: We have a double mutation that is present in roughly 3% of diagnosed SAD patients and that can predict SAD – well, mostly? Uh-huh. Not exactly a smoking gun is it? Yet it gets touted as a genetic basis for the disorder …

  • http://www.blogger.com/profile/04985103231803185085 blog friendly

    So by their own definition the makers of the DSM suffer from the following personality type?-

    “Compulsivity: The tendency to think and act according to a narrowly defined and unchanging ideal, and the expectation that this ideal should be adhered to by everyone”

    Who's to watch the watchers?

  • Anonymous

    This is all such utter nonsense. Where else in Medicine to people convene and vote on whether a disease or illness exists? I mean, do oncologists vote on whether or not pancreatic or lung cancers are diseases? Can we one day decide that diabetes is not a disease, all by committee vote? Let's face it: Psychiatric diagnoses are socially and culturally bound categories decided by men (and women) with vested interests (aka monetary) in the definitions. It is all a scam… and a sham.

  • dearieme

    Perhaps it's not just psychiatric diagnoses that are a sham? Neuroskeptic, you had been going to write about this woman's work.
    http://afamilyofshepherds.blogspot.com/2010/02/is-accused-murderer-dr-amy-bishop.html

    H/T a commenter at Gene Expression.

  • http://www.blogger.com/profile/06647064768789308157 Neuroskeptic

    Roger Bigod: Quite true – DSM-V is full of disorders that arguably shouldn't be there – Asperger's has got a better claim to be a distinct disorder than many of the disorders they've just invented for DSM-V (i.e. several decades of historical use, many experts e.g. Simon Baron-Cohen support it as a separate disorder…)

    So I don't know why they decided to get rid of it. I do think, though, that this kind of thing is going to be the end of the DSM's dominance. If they “abolish” Asperger's a lot of people, including I suspect a lot of researchers, are just going to keep using it and ignore the DSM-V. Which is probably no bad thing.

  • http://www.blogger.com/profile/06647064768789308157 Neuroskeptic

    dearieme: Hmm. well in the light of that very interesting post, I think I will write about it…

  • Anonymous

    Jeez I see that DSM-V will abolish personality disorders as illnesses! I can hardly wait to tell my ex-wife!!!

  • Anonymous

    I agree with Wondering: Psychiatric genetic studies are a complete joke. Stuttering? Schizophrenia? Depression? Gambling? Alcoholism? And on and on. The headlines scream that a gene or two have been found to explain these ills! But read the fine print and lo and behold it is usually a matter of one study that accounts for 3 or 4 or 9 percent of the variance or prevalence for the phenomena under consideration! Why don't the headlines scream “Genetic Studies Cannot Account for MORE than 90% of Psychiatric Illnesses? Just asking.

  • ML, MD

    The anonymous, and I don't doubt this is the same anonymous, makes the same mistake confusing psychiatric diseases with classification of psychiatric diagnoses. It would have been a forgivable mistake, if only I didn't explain to him the difference two weeks ago on this blog.

    I also believe that bringing together all diagnoses under one big umbrella (proposed change in Autistic disorders in DSM V) does great disservice to the field as it lumps together possibly dissimilar conditions. Instead, they should have split them into separate categories to study independently. If as a result of this research we learn that they are indeed the same disorder bringing them together, under one label, won't be hard.

  • Anonymous

    Hey ML,MD:
    Why don't you educate me again, you pompous ass. Do genetic studies of psychiatric DISEASE account for much more than three or five or nine percent of the DISEASE in question? I think not. By the way, I am still waiting for your explanation as to why a neurobiological illness such as schizophrenia fares much better in the Third World where they are devoid of your “neurobiological treatments.”

  • ML, MD

    Anonymous,
    I have no interest in bickering with you, we are not in the same league. I will ask you, however, to lower your voice and refrain from insults and rude tone. We are guests on this blog and your abusive language shows disrespect toward our gracious host and other guests. Thanks.

  • Anonymous

    Hey ML,MD:
    With all due respect to your obviously superior intellect, I submit it is you who is being rude and crude. To wit: We are not in the same league??? LOL. Who are you kidding? Have you noticed that you don't ever respond intelligently to the questions I pose to you? Why, you simply assert your “superiority” and claim that I am a mere ant for you to squash with your arrogant, but ultimately empty, over intellectualized “feet.” (Which you regard as “feat”). You must fashion yourself as a Greek God of sorts. Too bad DSM-V proposes to do away with the DISEASE of narcissism… you obviously have this ILLNESS in spades. Perhaps there is a genetic line in your family for this DISEASE? Maybe you have a NEUROBIOLOGICAL vulnerability to this ILLNESS OR DISORDER OR DIAGNOSIS? Who knows? But I don't give a damn. And I have not been rude to our gracious host by pointing this out to you! Perhaps therapy might be indicated? Just a suggestion.

  • Marcus

    Anonymous completely misses the point that psychiatric genetics is not trying to “prove” that certain mental “diseases” are “genetic”, it's not as simple as that. The point is that certain genes predispose one to go into a depressive slump when faced with an event that would just usually trigger grief, or certain genes cause one to become thought disordered and hear voices when they smoke too much weed. Same way certain genes cause some people to get lung ca. ,given exposure to carcinogens, and some people don't. It's about susceptibility/predisposition. No-one is saying schizophrenia is a like an autosomally dominant inherited disorder like Huntingtons. Anonymous you make yourself sound ignorant and make it obvious you don't understand pathology.

  • MikeS

    The DSM is incredibly representative of the problems with modern psychiatry. Instead of embracing interpersonal differences in personality, idiosyncracies, and lifestyles, they feel the need to diagnose everybody with some sort of disorder so they can come in to the office and get prescribed some drug that will just make their situation worse, with a fat check for the doctor and the pharmaceutical industry.

    It also encourages people to not take responsibility for their own problems. If you feel anxious every now and then, the best option is to work your way through it, perhaps trying to arrange your life and schedule to best accommodate your personal quirks, maybe seeking some professional psychotherapy if you're having a lot of problems. The other option is to see a psychiatrist that will promptly diagnose you with GAD and perhaps offer you a drug cocktail and put you on a lifelong medication dependence. Maybe you can also call up the SSDI and get a nice disability check. Thus you can stop taking responsibility for your own issues and just tell people “oh I have an anxiety disorder.”

    The “psychobiological dysfunction” aspect is laughable. Ever since it was discovered that antidepressants work on the serotonin systems, research has been seeking to confirm their backwards reasoning, that depression is caused by a “chemical imbalance” of serotonin, and 30 years of research has basically concluded that there is no imbalance at all, but drug companies are not letting that widespread belief die. The notion that taking an SSRI for depression is comparable to taking insulin for diabetes is just complete hokum. There is no evidence of any psychobiological dysfunction for most of the disorders in the DSM-V.

    Psychiatry is a business. A lot of these mental illnesses are left best treated with minor lifestyle adjustments or some psychotherapy. It seems like the DSM is trying to make everybody “normal”. What a boring world that would be.

  • http://www.blogger.com/profile/16894499836711589449 Leslie Dunne

    thank you i have been labeled all my life, off drink 14 years, only to find i am now a drug addict. and the list will remain endless as long as i seek help from the pros, with little or no life experance. sorry what do you call it when you cant read or spell???? Les. kind regards.

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No brain. No gain.

About Neuroskeptic

Neuroskeptic is a British neuroscientist who takes a skeptical look at his own field, and beyond. His blog offers a look at the latest developments in neuroscience, psychiatry and psychology through a critical lens.

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