Is the DSM-5 really a paradigm shift?

by Lauren Taylor

Last week, the American Psychiatric Association (APA) released the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Often referred to as the “Bible” of mental health professionals, the DSM it provides a common language and set of criteria for the identification of mental disorders. The standardization allows government and other funding bodies to set clear research agendas, the practitioner community to consistently bill third-party payers, and the work of psychiatry to be readily incorporated into other professional settings such as the legal and welfare systems.

The DSM-5 follows (surprise!) four previous editions of the manual. The first DSM was released in 1952, followed by DSM-II in 1968. These early editions bear little resemblance on the more modern ones, as neither provided clear classification schemes for illnesses. Instead, psychoanalysis’ hold over the profession prioritized the process of uncovering the psychological roots of an individual’s abnormal behavior over the categorical naming of one disease versus another. DSM-III, released in 1980, bears primary responsibility for moving the profession to a symptom-based taxonomy of categorical diseases. Its successor, DSM-IV, and now DSM-5, largely followed in suit.

Efforts to produce this latest version began as early as 1999, led by a task force of 28 authors who issued forth the goal of a ‘paradigm shift’ in the way that psychiatry and mental health defined its scope. Since then, some 300 advisors and 1,500 experts weighed in on its creation. More than 10,000 comments were also solicited from the lay public as to what should make the cut as a “mental disorder.”

The most significant changes made to DSM-5 have been comprehensively detailed by that APA and a litany of mental health professionals in other commentaries. Most controversially, several diagnoses, including Asperger’s Syndrome, have been removed, while others, such as Disruptive Mood Dysregulation Disorder (DMDD) have been added to the manual. The DSM-5 authors determined that Asperger’s is best understood as one of many forms of Autism Spectrum Disorder, much to the chagrin of several powerful Asperger’s advocates and lobbies, while the addition of DMDD has been added in an effort to better detect early signs of bipolar disorder and other more serious conditions at a young age. Deemed by some “the temper tantrum disorder”, DMDD drawn powerful criticism as a pediatric diagnosis based on what some see as all-too-common qualification criteria: a child need only present with an opposition to authority and irrational temper, among other, equally common, behaviors in children.

While these sort of additions and subtractions from the manual may appear to be a simple rearranging of deck chairs, the authority vested in the DSM means that changes can have profound impact on millions of mentally ill Americans and their families. On the bright side, many insurance companies may be more likely to cover professional treatment for someone who chronically hoards (hoarding disorder has been added as a clinical diagnosis), while children who were formerly borderline autistic may not qualify for treatment in light of tightened guidelines for that diagnosis (guidelines for Attention Deficit Hyperactivity Disorder, however, have been relaxed). Compulsive gamblers, who may otherwise be considered social derelicts, may benefit from a reduction in stigma associated with the medicalization of their impulse, while a parent mourning the loss of a dead child may suffer further personal or professional angst from being clinically diagnosed with a newly broadened form of major depressive disorder.

Historically speaking, the trend of the DSMs has been to extend the authority of psychiatry to new realms of human life. With each iteration, the size of the manual has grown—DSM-I was 130 pages, DSM-5 is just shy of 1,000—while the specificity of most diagnoses has remained in question. Several of the new diagnoses brought forth by the DSM-5 such as caffeine withdrawal and binge eating (defined by eating a large quantity of food in a shorter time than is typical at least 12 times in 3 months) that have been held up in the press and blogosphere as paragons of psychiatry run amok. While authors have suggested that they were conservative and ruthlessly scientific in their handling of diagnostic additions, the Chair of the DSM-IV committee recently suggested that lame additions to DSM-5 “will start a half or dozen or more new fads [in psychiatry] which will be detrimental to the misdiagnosed individuals and costly to our society.”,

In the view of these critics, the DSM-5 represents a narrowing of the boundaries around what constitutes normal existence, and a dangerous pathologizaiton of the human condition. To this point, a recent nationwide diagnostic census based on DSM claimed that the majority of Americans have or have had a mental disorder, which may concern Americans who see a rhetorical irony in the majority being disordered. Fears regarding the use and abuse of psychotropic drugs in the treatment of children often follow in this line of thought.

Others, however, suggest that the broadened definitions of mental illness represent a newly progressive approach to psychiatry in which the mental health of a population may be conceptualized on a continuum. Evidence published in the peer-review literature is already signaling a more complex set of factors influencing mental health than had previously been surmised, resulting in any number of disease presentations. The implications of these and future, similar findings may help to decrease the ease with which we currently stigmatize those now considered mentally ill. The fact that we all may see ourselves in one diagnostic bucket or another may therefore represent a conceptual strength rather than a weakness of the DSM-5.

Despite the authors’ aspirations and the critics’ hype, the DSM-V represented a continuation of a trend (gated) rather than a paradigm shift. A paradigm shift may well be coming, but like DSM III and IV, the document pointed to a continued breakdown in the consensus around traditional definition of mental illness more so than it posited anything truly new in its place.

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Lauren studies health care ethics at Harvard Divinity School.

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