Tuesday, February 9, 2010

From Sad to Mad—the new DSM-V is to be issued in 2012

Part 1--Mystery surrounds picking the diagnoses to be included

The bible of the psychiatric world, the Diagnostic and Statistical Manual of Mental Disorders, produced by the American Psychiatric Association, is being rewritten to produce a new version in 2012, a dozen years since the last revision known as the DSM-IV-TR. A draft was issued Feb. 10 to show the world some new diagnoses, like temper dysregulation, and for the first time it calls for binge eating and gambling to be considered disorders.

The fifth revision of this masterful document, which is routinely used by mental health professionals when treating patients and helps insurance companies decide what disorders to cover, serves as well as for clinicians, courts, prisons, drug companies and agencies that regulate drugs. Countries all over the world treat the DSM as gospel, so even minor changes and additions will have powerful ripple effects on mental health diagnoses around the world, notes Christopher Lane writing in the Los Angeles Times (Nov. 16, 2008).

As patients and their families know, a doctor, clinician or other practitioner had better line up treatment that is consistent with one or more of the codes for the individual disorders listed in the diagnostic manual. That's so Medicaid, Medicare or other insurance or NYS-subsidized mental health services, which have their own lists of codes (these may correlate directly to the DSM) can determine which get reimbursed and which do not. These decisions become major issues for community mental health providers in housing, rehabilitation, social and vocational programs, as well as clinics, hospitals and emergency facilities. Some services are declared non-medical or unauthorized for the patient's circumstances and won't be reimbursed.

There are several themes here: (1) how the authors of the new volume deal with the increasing clutter of diagnoses and how they separate them into definable diseases or various non-disease conditions; (2) the secrecy felt to be needed by the authors in researching and analyzing these disorders to avoid bias and lend scientific reliability to the DSM's goals; and (3) whether the ever-expanding numbers of disease categories reflect the pressures of doctors, the medical products industry and drug companies to make bigger profits from the over-diagnosis of these disorders.

In press releases Feb. 10 the draft document is said to leave out obesity as a formal diagnosis, internet addiction or sex addiction, as some have proposed. A bone of contention in the new document is that the checklists of symptoms a patient needs to have to add up to a disorder will be replaced with a scale of severity for every disorder. The experts at the APA say the checklists don't really capture how mental disorders work in the real world.

The DSM is like a cookbook of recipes. For example, in diagnosing major depression, doctors use a checklist of nine symptoms. Patients who meet five out of nine criteria can be said to have major depression. Under the newly proposed system, the severity of the symptoms a patient has would be factored into the diagnosis. The DSM isn't about treatments, unlike the PDR (Physicians Desk Reference) created by the industry for prescription drugs and used as guidelines for treatment.

Discussion of what goes in the manual already has drawn hot reaction from critics and supporters in articles and a book or two over the way the DSM-IV treats the huge array of illnesses and common emotional attitudes like shyness and sadness. Scientists are battling over whether the next revision should be done openly so mental health professionals and the public can follow along, or whether the debate should be held in secret.

As the Lane article puts it, “hanging in the balance is whether, three years from now a set of questionable behaviors with names such as apathy disorder, parental alienation syndrome, premenstrual dysphoric disorder, compulsive buying disorder, internet addiction and relational disorder will be considered full-fledged psychiatric illnesses.” It may sound like an insignificant spat, he remarks, “but the debates have far-reaching consequences. To large numbers of experts, apathy, compulsive shopping and parental alienation are symptoms of psychological conflict rather than full scale mental illnesses.” (Roy Neville)


  1. "Strangely, the DSM is all about diagnoses—definitions and classification of mental and emotional disorders--and doesn't deal with treatments at all. It's not like the PDR (Physicians Desk Reference) created by the industry for prescription drugs and used as guidelines for treatment. You'd think the DSM authors would want to assure that treatments are prescribed that align nicely with their assiduous presentation of symptoms."

    There are so many types of therapy and variables in this area I don't believe this would ever be possible. Medications are chemicals that can be measured to some degree predictably. We know how Lithium effects individuals with the Bipolar disorder as an example. We know how a beta blocker effects the heart muscle. Therapies on the other hand many times overlap and a therapist or provider utilizes the best combination the out come can be witnessed but the ingrediates can't be really measured. I find too many variables in therapies where as we have more of a physical reaction scientifically measured with medications.

    In regards to what the new book covers....

    I am not a professional or expert. Just a lay person. I don't believe behavioral issues should be a part of the DMS book. IE Gambling or Internet addiction, Borderline personality behavior in my layman view are not mental brain chemistry disorders. I believe they should have their own behavior diagnosis book. I don't see them as a mental illness like a thought disorder, mood disorder or physical addiction issue.

  2. Found this online draft copy of the DSM-V thought you might find it an interesting site. There is a place for folks to respond with their opinions on it too.