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)