DSM-5 PUBLISHED MAY 2013 + 'The Ten Most Common Citicisms' by Professor Allan Frances - Courtesy of Wikipedia

DSM-5 (2013)

Main article: DSM-5

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM-V, was approved by the Board of Trustees of the American Psychiatric Association (APA) on December 1, 2012.^[38] Published on May 18, 2013,^[39] the DSM-5 contains extensively revised diagnoses and, in some cases, broadens diagnostic definitions while narrowing definitions in other cases.^[40] The DSM-5 is the first major edition of the manual in twenty years,^[41] and the Roman numerals numbering system has been discontinued to allow for greater clarity in regard to revision numbers. A significant change in the fifth edition is the proposed deletion of the subtypes of schizophrenia.^[42][43] During the revision process, the APA website periodically listed several sections of the DSM-5 for review and discussion.^[44]

DSM-IV-TR

DSM-IV-TR, the predecessor to the most current DSM edition, the DSM-5

Categorization

The DSM-IV is a categorical classification system. The categories are prototypes, and a patient with a close approximation to the prototype is said to have that disorder. DSM-IV states, "there is no assumption each category of mental disorder is a completely discrete entity with absolute boundaries" but isolated, low-grade and noncriterion (unlisted for a given disorder) symptoms are not given importance.^[45] Qualifiers are sometimes used, for example mild, moderate or severe forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning," although DSM-IV-TR removed the distress criterion from tic disorders and several of the paraphilias due to their egosyntonic nature. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.

Multi-axial system

The DSM-IV organizes each psychiatric diagnosis into five dimensions (axes) relating to different aspects of disorder or disability:

• Axis I: All psychological diagnostic categories except mental retardation and personality disorder
• Axis II: Personality disorders and mental retardation
• Axis III: General medical condition; acute medical conditions and physical disorders
• Axis IV: Psychosocial and environmental factors contributing to the disorder
• Axis V: Global Assessment of Functioning or Children's Global Assessment Scale for children and teens under the age of 18

Common Axis I disorders include depression, anxiety disorders, bipolar disorder, ADHD, autism spectrum disorders, anorexia nervosa, bulimia nervosa, and schizophrenia.

Common Axis II disorders include personality disorders: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder, avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder; and intellectual disabilities.

Common Axis III disorders include brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders.

Cautions

The DSM-IV-TR states, because it is produced for the completion of federal legislative mandates, its use by people without clinical training can lead to inappropriate application of its contents. Appropriate use of the diagnostic criteria is said to require extensive clinical training, and its contents "cannot simply be applied in a cookbook fashion".^[46] The APA notes diagnostic labels are primarily for use as a "convenient shorthand" among professionals. The DSM advises laypersons should consult the DSM only to obtain information, not to make diagnoses, and people who may have a mental disorder should be referred to psychological counseling or treatment. Further, a shared diagnosis or label may have different causes or require different treatments; for this reason the DSM contains no information regarding treatment or cause. The range of the DSM represents an extensive scope of psychiatric and psychological issues or conditions, and it is not exclusive to what may be considered "illnesses".

Sourcebooks

The DSM-IV does not specifically cite its sources, but there are four volumes of "sourcebooks" intended to be APA's documentation of the guideline development process and supporting evidence, including literature reviews, data analyses and field trials.^{[47][48][49][50]} The Sourcebooks have been said to provide important insights into the character and quality of the decisions that led to the production of DSM-IV, and hence the scientific credibility of contemporary psychiatric classification.^[51][52]

Criticism

Reliability and validity concerns

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The revisions of the DSM from the 3rd Edition forward have been mainly concerned with diagnostic reliability—the degree to which different diagnosticians agree on a diagnosis. It was argued that a science of psychiatry can only advance if diagnosis is reliable. If clinicians and researchers frequently disagree about a diagnosis with a patient, then research into the causes and effective treatments of those disorders cannot advance. Hence, diagnostic reliability was a major concern of DSM-III. When the diagnostic reliability problem was thought to be solved, subsequent editions of the DSM were concerned mainly with "tweaking" the diagnostic criteria. Unfortunately, neither the issue of reliability (accurate measurement) or validity (do these disorders really exist) was settled. However, most psychiatric education post DSM-III focused on issues of treatment—especially drug treatment—and less on diagnostic concerns. In fact, Thomas R. Insel, M.D., Director of the NIMH, has recently stated the agency would no longer fund research projects that rely exclusively on DSM criteria due to its lack of validity.^[53]

Superficial symptoms

By design, the DSM is primarily concerned with the signs and symptoms of mental disorders, rather than the underlying causes. It claims to collect them together based on statistical or clinical patterns. As such, it has been compared to a naturalist’s field guide to birds, with similar advantages and disadvantages.^[54] The lack of a causative or explanatory basis, however, is not specific to the DSM, but rather reflects a general lack of pathophysiological understanding of psychiatric disorders. As DSM-III chief architect Robert Spitzer and DSM-IV editor Michael First outlined in 2005, "little progress has been made toward understanding the pathophysiological processes and etiology of mental disorders. If anything, the research has shown the situation is even more complex than initially imagined, and we believe not enough is known to structure the classification of psychiatric disorders according to etiology."^[55]

The DSM's focus on superficial symptoms is claimed to be largely a result of necessity (assuming such a manual is nevertheless produced), since there is no agreement on a more explanatory classification system.^{[citation needed]} Reviewers note, however, that this approach is undermining research, including in genetics, because it results in the grouping of individuals who have very little in common except superficial criteria as per DSM or ICD diagnosis.^[3]

Despite the lack of consensus on underlying causation, advocates for specific psychopathological paradigms have nonetheless faulted the current diagnostic scheme for not incorporating evidence-based models or findings from other areas of science. A recent example is evolutionary psychologists' criticism that the DSM does not differentiate between genuine cognitive malfunctions and those induced by psychological adaptations, a key distinction within evolutionary psychology, but one widely challenged within general psychology.^[56][57][58] Another example is a strong operationalist viewpoint, which contends that reliance on operational definitions, as purported by the DSM, necessitates that intuitive concepts such as depression be replaced by specific measurable concepts before they are scientifically meaningful. One critic states of psychologists that "Instead of replacing 'metaphysical' terms such as 'desire' and 'purpose', they used it to legitimize them by giving them operational definitions...the initial, quite radical operationalist ideas eventually came to serve as little more than a 'reassurance fetish' (Koch 1992) for mainstream methodological practice."^[59]

Dividing lines

Despite caveats in the introduction to the DSM, it has long been argued that its system of classification makes unjustified categorical distinctions between disorders, and uses arbitrary cut-offs between normal and abnormal. A 2009 psychiatric review noted that attempts to demonstrate natural boundaries between related DSM syndromes, or between a common DSM syndrome and normality, have failed.^[3] Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.^{[60][61][62][63]}

In addition, it is argued that the current approach based on exceeding a threshold of symptoms does not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual versus a psychological response to adverse situations.^[64][65] The DSM does include a step ("Axis IV") for outlining "Psychosocial and environmental factors contributing to the disorder" once someone is diagnosed with that particular disorder.

Because an individual's degree of impairment is often not correlated with symptom counts, and can stem from various individual and social factors, the DSM's standard of distress or disability can often produce false positives.^[66] On the other hand, individuals who do not meet symptom counts may nevertheless experience comparable distress or disability in their life.

Cultural bias

Some psychiatrists also argue that current diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables.^[67] Advocating a more culturally sensitive approach to psychology, critics such as Carl Bell and Marcello Maviglia contend that the cultural and ethnic diversity of individuals is often discounted by researchers and service providers.^[68] In addition, current diagnostic guidelines have been criticized as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criteria set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only demonstrate consistency, not legitimacy.^[67] Cross-cultural psychiatrist Arthur Kleinman contends that the Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: the fact that disorders or concepts from non-Western or non-mainstream cultures are described as "culture-bound", whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, is to Kleinman revelatory of an underlying assumption that Western cultural phenomena are universal.^[69] Kleinman's negative view towards the culture-bound syndrome is largely shared by other cross-cultural critics, common responses included both disappointment over the large number of documented non-Western mental disorders still left out, and frustration that even those included were often misinterpreted or misrepresented.^[70] Many mainstream psychiatrists have also been dissatisfied with these new culture-bound diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of the DSM-III, has held the opinion that the addition of cultural formulations was an attempt to placate cultural critics, and that they lack any scientific motivation or support. Spitzer also posits that the new culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved. In general, the mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only significant to specific symptom presentations.^[67]

Medicalization and financial conflicts of interest

It has also been alleged that the way the categories of the DSM are structured, as well as the substantial expansion of the number of categories, are representative of an increasing medicalization of human nature, which may be attributed to disease mongering by psychiatrists and pharmaceutical companies, the power and influence of the latter having grown dramatically in recent decades.^[71] Of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half have had financial relationships with the pharmaceutical industry at one time, raising the prospect of a direct conflict of interest.^[72] The same article concludes that the connections between panel members and the drug companies were particularly strong in those diagnoses where drugs are the first line of treatment, such as schizophrenia and mood disorders, where 100% of the panel members had financial ties with the pharmaceutical industry.^[72] In 2005, then American Psychiatric Association President Steven Sharfstein released a statement in which he conceded that psychiatrists had "allowed the biopsychosocial model to become the bio-bio-bio model".^[73]

However, although the number of identified diagnoses has increased by more than 200% (from 106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argue it almost entirely represents greater specification of the forms of pathology, thereby allowing better grouping of more similar patients.^[3] William Glasser, however, refers to the DSM as "phony diagnostic categories", arguing that "it was developed to help psychiatrists – to help them make money".^[74] In addition, the publishing of the DSM, with tightly guarded copyrights, has in itself earned over $100 million for the American Psychiatric Association.^[7]

Consumers and survivors

A consumer is a person who accesses psychiatric services and may have been given a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders, while a survivor self-identifies as having survived psychiatric intervention and the mental health system (which may have involved involuntary commitment and involuntary treatment). Some are relieved to find that they have a recognized condition to which they can give a name. Indeed, many people self-diagnose. Others, however, feel they have been given a "label" that invites social stigma and discrimination (i.e. mentalism), or one that they simply do not feel is accurate. Diagnoses can become internalized and affect an individual's self-identity, and some psychotherapists find that this can worsen symptoms and inhibit the healing process.^[75] Some in the Psychiatric survivors movement (more broadly the consumer/survivor/ex-patient movement) actively campaign against their diagnosis, or its assumed implications, and/or against the DSM system in general. It has been noted that the DSM often uses definitions and terminology that are inconsistent with a recovery model, and that can erroneously imply excess psychopathology (e.g. multiple "comorbid" diagnoses) or chronicity.^[76]

DSM-5 critiques

Psychiatrist Allen Frances has been critical of proposed revisions to the DSM-5. In a 2012 article, Frances warned that if this DSM version is issued unamended by the APA, it will "medicalize normality and result in a glut of unnecessary and harmful drug prescription."^[77] In a December 2, 2012 blog post in Psychology Today, Frances lists the ten "most potentially harmful changes" to DSM-5:^[78]

^{LOOK OUT 1984 IS HERE}

• Disruptive Mood Dysregulation Disorder, for temper tantrums which are normal
• Major Depressive Disorder, includes normal grief and medicating with anti-depressants
• Minor Neurocognitive Disorder, for normal forgetting in old age
• Adult Attention Deficit Disorder, encouraging psychiatric prescriptions of stimulants
• Binge Eating Disorder, for excessive eating
• Autism change, classifying "introversion" as a form of autism which is crazy
• First time drug users will be lumped in with addicts
• Behavioral Addictions, making a "mental disorder of everything we like to do a lot."
• Generalized Anxiety Disorder, includes everyday worries so we can all end up being drugged
• Post-traumatic stress disorder, changes opening "the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings."

Frances and others have published debates on what they see as the six most essential questions in psychiatric diagnosis:^[79]

• are they more like theoretical constructs or more like diseases
• how to reach an agreed definition
• whether the DSM-5 should take a cautious or conservative approach
• the role of practical rather than scientific considerations
• the issue of use by clinicians or researchers
• whether an entirely different diagnostic system is required.

In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that has brought thousands into the public debate about the DSM. Approximately 14,000 individuals and mental health professionals have signed a petition in support of the letter. Thirteen other American Psychological Association divisions have endorsed the petition.^[80] Robbins has noted that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences.^[81]

See also

• Relational disorder (proposed DSM-5 new diagnosis)
• Classification of mental disorders
• Chinese Classification and Diagnostic Criteria of Mental Disorders
• DSM-IV Codes
• Global Assessment of Functioning (GAF) Scale
• International Statistical Classification of Diseases and Related Health Problems (ICD)
• Psychodynamic Diagnostic Manual
• Structured Clinical Interview for DSM-IV (SCID)
• Diagnostic classification and rating scales used in psychiatry
• Research Domain Criteria (RDoC), a framework being developed by the National Institute of Mental Health
• Rosenhan experiment

References