Sunday, June 2, 2013

Reflections on DSM-5: Strengths and Controversies

The DSM-5 is a tool used by mental health professionals for case conseputalization
A couple weeks ago, the American Psychiatric Association (APA) unveiled the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), triggering headlines such as "DSM-5 is here: What the controversial new changes mean for mental health care" and "Controversial update to psychiatry manual, DSM-5, arrives."

Aaron Norton, LMHC, presents on DSM-5
The buzz word, of course, is "controversy."  And why not?  Few, if any, areas of modern medicine are more controversial than Psychiatry.  Mental illness remains, in many respects, stigmatized by society-at-large.  Many struggle to accept mental disorders as legitimate medical conditions.  Throw in the fact that although the DSM was created to aid trained mental health professionals with case conceptualization for treatment planning, others use it to build a case for or against someone in criminal and civil case proceedings, disability determination, and eligibility for a number of social programs. 

The stakes are high and the implications are vast, so any changes in the way mental health professionals categorize, label, or conceptualize mental disorders are bound to be met with some degree of skepticism or criticism both within and outside the field.  I think that's just par for the course.

But what are the hot button issues with this revision?  What are critics alleging?  I'll briefly explore two of the most commonly discussed controversies:

1) The creation of new disorders pathologizes normal human behaviors and experiences.  Disruptive Mood Dysregulation Disorder, Premenstrual Dysphoric Disorder, Mild Neurocognitive Disorder, and Binge Eating Disorder are among the most controversial additions, and the removal of the Bereavement exclusion from the criteria for a Major Depressive episode has triggered criticism that normal human grief has been unnecessarily labeled a disorder.  I think this is a valid concern in the sense that I am attuned to the risk of medicalizing unpleasant or abnormal human experience.  But when I read the criteria for these new disorders, it seemed obvious to me that the new edition isn't targeting common temper tantrums, the occasional fast food drive thru experience, mild absentmindedness, or the typical mood fluctuation that many women experience during "that time of the month."  I think the criteria paint a fairly clear picture of a severe symptom presentation causing a clinically significant degree of impairment or distress that often warrants treatment.  And because I recognize that the neurobiology of a clinically depressed person isn't different if that individual is grieving the loss of a loved one, removal of the Bereavement exclusion makes logical sense to me.  Moreover, there are several examples in the DSM-5 of the de-stigmatization of abnormal human experiences.  Changes in the category of Paraphilic Disorders and the re-classification of Gender Dysphoria are, I think, great examples.  Of course, the DSM is essentially the brainchild of the APA, an association that exclusively represents psychiatrists vs. mental health professionals who treat mental illness without prescribing medication (e.g. counselors, therapists, psychologists, clinical social workers), so some are concerned that the APA is in bed with "Big Pharma," and therefore benefits from classifying relatively benign human experiences as a form of mental illness.  Meanwhile, while some believe that the DSM-5 revisions will cause an increase in the number of Americans who are deemed "mentally ill," others are concerned that revisions will squeeze some Americans out of diagnostic labels.  For example, some critics of the merger of Aperger's Disorder into Autism Spectrum Disorder fear that some individuals currently diagnosed with Asperger's won't meet the new diagnostic criteria despite the APA's findings to the contrary.

2) The classification system is arbitrary and/or not organized based on the neurobiological characteristics of the disorder.  Just prior to the release of the DSM-5, Dr. Thomas Insel, the Director of the National Institutes of Mental Health, alleged that "the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure," opining that "patients with mental disorders deserve better."  I certainly agree
Thomas Insel, MD
that the DSM's classification system is not ideal, but I also believe that mental health is a complex subject area; it can't necessarily be reduced to a set of data points extrapolated from a routine lab test.  As we continue to develop new technologies for study of the human brain, I imagine the way we classify mental disorders will continue to evolve.  Indeed, there are several examples of changes in the DSM-5 that stem from advancements in the field of Neuroscience.  Gambling Disorder shifted into the new Substance Use and Addictive Disorders chapter due to commonalities in the underlying neurobiology of both addictive experiences.  Asperger's Disorder was merged in with Autism and two other developmental disorders based on evidence that the four disorders were, on a biological level, varying degrees of severity of the same disorder.  The DSM-IVTR chapter entitled "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence" was eliminated, and disorders previously listed in that chapter were reorganized into chapters of disorders with similar underlying neurobiological processes.  Lastly, I'm not certain that any critics of the current classification system have any better ideas at the present.  Two weeks after posting his criticisms of the DSM-5, Insel co-wrote a press release conceding that "Today, the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), along with the International Classification of Diseases (ICD) represents the best information currently available for clinical diagnosis of mental disorders."

So what do I like about the DSM-5?  I like that several revisions reinforce the notion that the distinction between the body and brain are, essentially, more myth than fact.  People often think of mental health as a distinctively separate realm from physical health, as though the two were entirely disconnected spheres of the human experience.  But what are mental disorders if not biological?  They involve genetics, neurotransmitters and hormone levels, brain structures, electrical impulses that travel through the body, encoding of information into short-term and long-term memory, organization of various mental constructs imprinted through life experience, and the intriguing interface between environmental exposure and internal biology (e.g. epigenetics).  Even "non-medical" treatments such as psychotherapy are, in essence, biological interventions in the sense that they involve refined integration of the brain and trigger neurological processes such as neuroplasticity and neurogenesis.  The field of psychoneuroimmunology is bursting with findings substantiating the connection between Mind and Body.  Consequentially, I'm pleased with subtle verbiage changes such as scrapping the phrase "due to a general medical condition" for a more accurate word choice of "due to another medical condition."  And I'm thrilled that somatic disorders can now be diagnosed even if an individual has a known, legitimate, diagnosed medical condition.

I also like that the classification system is less dichotomous.  Several disorders have been merged together and conceptualized as varying points on a spectrum.  The truth is that two people with the same diagnosis can experience dramatically different levels of severity and functioning.  

Finally, the DSM-5 is overall a somewhat more simplified and streamlined product than the DSM-IVTR.  Its shorter in length with several examples of less convoluted wording.  Some old diagnostic labels that have become pejorative labels have been renamed (e.g. "Mental Retardation" became "Intellectual Disability").

All in all, I think the DSM-5 is an improved product in comparison to the DSM-IVTR. Its imperfect and flawed, like any organizational system, but it's probably the best that we have for now.  We'll see what changes with future revisions.

Highlights of Changes from DSM-IVTR to DSM-5
APA's DSM-5 website

Want to learn more about DSM-5 revisions?  If your agency or practice would benefit from an-service training, ask me about my presentation on DSM-5.  I'm available for workshops, conferences, and in-service training in the Tampa Bay area.

Aaron Norton, LMHC provides training on DSM-5

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