There has been a lot of controversy last month about the release of the DSM 5, which is a manual that is used in the US to diagnose mental disorders and code them for insurance coverage. The terms you hear like OCD, Bipolar Disorder, Autism, Schizophrenia, etc are found in this manual with criteria that must be met, background information, and other important information about the disorder. The 5 in the DSM 5, means this is the 5th Edition (more or less, there was a DSM IV TR which was a Text Revision.) And the DSM stands for Diagnostic and Statistical Manual of Mental Disorder. The first edition was publish in 1952 and the last publication before this new edition was in 2000. There has been a lot of things that have changed since 1952 in regards to recognizing and treating disorders, classifying disorders in similar “families” like Major Depressive Disorder, Dysthymic Disorder, Bipolar Disorder, and Cyclothymic Disorder which fall into the Mood Disorder category or family. Changes in how disorders are named such as Manic Depressive Disorder which is now Bipolar Disorder and Aspergers Syndrome which is now an Autistic Spectrum Disorder. The removal of disorders when culture and society changes, examples are Homosexuality and Gender Identity Disorder (if you considered yourself transgender, you could have been diagnosed with this.) The number of disorders has also changed as things have been removed and other disorders added, much more being added. Another reason for the increase in disorders is the fact that some disorders that professionals have found to be prevalent in the population which were before thought of as under an umbrella diagnosis; an example of this is the new skin picking disorder and hoarding which were formerly thought of as sub types or symptoms under Obsessive Compulsive Disorders. So now that you have a little history on the DSM and how and why they make changes I will explain what I think of some of the new changes both ones that are controversial and others which may have not gotten as much press.
One of the biggest stories was when Thomas Insel, the director of the National Institute of Mental Health (NIMH) publicly stated that their orginization would no longer be using the DSM for their research methods. He went on to say:
Patients with mental disorders deserve better. But what exactly is better? What alternative do we have to categorizing patients according to their symptoms? Where are the hard data, the blood test, the biopsy, the EKG for diagnosing troubles of the mind?
Insel wants the government funded agency to instead focus on symptoms that may be part of different disorders rather than specific diagnosis and a focus on evidence based tests. For example, allowing people with depressive symptoms that may be diagnosed with different diagnosis (example: Major Depressive Disorder or Bipolar Disorder) to participate in the same research studies in hopes to find brain based research that ties to the symptom of depression. With this hypothetical new knowledge, researchers believe they could make better medications that could target specific symptoms; and maybe even later see (as in brain imaging or gene sequencing, etc) differences between agitated depression and say catatonic depression to make specific medications for those symptoms.
My response to this is: That I think this idea is great in theory but that we haven’t made any head way in it in the past. I think we should definitely try to find evidence based tests that can help us recognize symptoms and disorders and help with effective treatment. However, I think we aren’t there yet and to change the entire focus on to biological research of specific symptoms is just not possible at this time. In my opinion they should spend some time researching based solely on symptoms, some time on disorders as they are classified now, and other time figuring out how and why the treatments that do work work. I also believe that him being in such a public figure and some would assume spokesperson for the NIMH that he would be careful what his opinion is and how the words he says may be taken.
An excerpt from an interview with NPR:
FLATOW: Well, what is your problem? Tell us what your problem – why you’ve decided to not use that book so much.
INSEL: We’re not saying that clinicians shouldn’t use it. One way to think about this is DSM is really what we have, along with ICD, but those are really for the bedside. And I’m talking to an audience in the biomedical research community that’s at the bench, not at the bedside, most of the time.
And so, for the bench, we’re looking for some way to do just what Jeff Lieberman said a moment ago: finding a way to deconstruct these classifiers and to say hey, yes this is what we currently call schizophrenia. This is what we currently call autism spectrum disorder, but perhaps that’s not one problem, but multiple, five, six, seven, eight different diseases that are contributing.
Let’s do the science without the presumption that it’s a single disease. Let’s do the science with the assumption that we have to actually pull this apart and begin to understand the subtypes if we’re going to get to more selective treatments
Which kind of reinforces my point of being careful with his words, because he is specifying here he meant it just not be used by researchers but as you can tell people assume he means everyone even mental health professionals. Also another reason I am in favor of the DSM is that it puts common names to groups of symptoms that lead to some understanding, though obviously not perfect. If my therapist, case manager, psychiatrist, and primary care physician are talking and here the term Borderline Personality Disorder or Depression they have a general idea and understanding. Also, hearing a diagnosis helps your problems seem real and meeting others with similar disorders can create a sense of community and support- things like this happen daily at support groups for things like OCD, addictive behaviors, and even non-specific diagnosis, but symptoms like codependency, grief, or specific stressers.
The removal of Aspergers Syndrome from the DSM where there are now Autistic Spectrum Disorders. With this topic I go both ways in some regards. Aspergers Syndrome is commonly refereed to a less severe version of Autism or high-functioning Autism in some cases, I don’t like this and never have. When you say your child has high-functioning Autism you are implying that most Autism is low-functioning- I think with the symptoms that would normally classify you for a diagnosis of Aspergers Syndrome now falling on the Autistic Spectrum many more people will use terms like high-functioning and low-functioning to determine where the person falls on the spectrum. I prefer terms in severity, duration, and intensity that have less stigma attached to it.
Another big issue the change in grief or bereavement in the diagnosis of Major Depressive Disorder. Prior to the DSM 5 bereavement was an excluding factor, meaning that if you had the symptoms of Major Depressive Disorder for 2 weeks or more you could not meet the criteria on a bereavement exclusion. There are a couple things that could over ride this that I didn’t learn about until reading this from a post on World of Psychology:
An exception could be made only in certain cases; for example, if the patient were psychotic, suicidal, or severely impaired
I think allowing bereavement to be added is a positive step. I believe some people who may have a predisposition to Depression may get their illness triggered by a loss, in a similar way drug use can trigger schizophrenia in people who are predisposed. Also bereavement affects everyone different, you can tell by the quote above some reactions that can happen. Also many people need therapy services when dealing with the loss of a loved one and just because you get a Depression diagnosis doesn’t mean you have to take medication it could get you eligible for counseling services that may not be covered unless you have a diagnosis.
I am happy about the removal of Gender Identity Disorder from the manual this year and think it’s a great step for the LGBT community, especially youth who are more susceptible to be diagnosed and treated for this disorder.
I approve of gambling being added into the section on Addictive Disorders, I have seen first hand the damage a gambling addiction can have on people and am glad with the addition people more people will be treated and covered my insurance. Some people fear with this inclusion of an addiction being based on a behavior that eventually other behaviors will be added like internet addiction or video game addiction- I am not sure if this will happen or not but people should focus on the now rather than speculating about the future. If the internet or video gaming becomes a prevalent and disabling addiction that it may be added at a latter point and I think both those descriptions can apply to gambling addiction.
I have talked in a prior post about my views on the addition of Disruptive Mood Dysregulation Disorder (DMDD) to stop or redirect childhood bipolar diagnosis, I also talk about the personality disorders not being changed at this time and a little about the changes in the Autistic Spectrum.