Tag Archives: DSM

‘Psychiatric Bible’ Tackles Grief, Binge Eating & Drinking

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By Ashley Hayes, CNN

Grief after the loss of a loved one may be considered major depression, according to the new psychiatric manual.

Grief after the loss of a loved one may be considered major depression, according to the new psychiatric manual.

After years of controversy, the latest version of the “psychiatric bible” — the Diagnostic and Statistical Manual of Mental Disorders — has been released.

The DSM-5 (fifth edition)’s introduction, over the weekend at the American Psychiatric Association’s annual meeting, marks “the end of more than a decade’s journey in revising the criteria for the diagnosis and classification of mental disorders,” the association says on the DSM-5 website.

The manual includes the criteria used by mental health professionals to diagnose patients. It’s also used by insurance companies, schools and other agencies responsible for covering and creating special provisions for individuals with developmental or mental disorders.

The overhaul — the first for the DSM since 1994 — has not come without opposition from activists, some grass-roots organizations and even the National Institute of Mental Health, which last month said it was launching a project aimed at laying the foundation for a new classification system and would be “re-orienting its research away from DSM categories.”

Are we over-diagnosing mental illness?

Here are five ways the DSM changes may affect you:

Bereavement or depression?

Previously, clinicians were advised against diagnosing major depression in people within two months after the death of a loved one: the “bereavement exclusion.”

The DSM-5 removes the exclusion, a move the psychiatric association says “helps prevent major depression from being overlooked and facilitates the possibility of appropriate treatment including therapy or other interventions.”

Research has shown that for some people, the death of a loved one can precipitate major depression — much like other stressors such as losing a job, the association says on the DSM-5 website. But “bereavement is the only life event and stressor specifically excluded from a diagnoses of major depression” in previous manuals.

Binge eating is officially an eating disorder

Binge eating was approved as its own category of eating disorder in the DSM-5. It’s defined as “recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control.”

According to the association, the move is aimed at “increasing awareness of the substantial differences between binge eating disorder and the common phenomenon of overeating. While overeating is a challenge for many Americans, recurrent binge eating is much less common, far more severe, and is associated with significant physical and psychological problems.”

Binge drinkers may be diagnosed as mild alcoholics

The revised DSM collapses the medical distinction between problem drinking and alcoholism. Some experts say this could lead college binge drinkers, for example, to be mislabeled as alcoholics, a diagnosis that may follow them into adulthood.

Prior DSM editions included “alcohol abuse,” along with the more serious “dependence.” However, the DSM-5 will make “alcohol use disorder” a single condition.

“The field of substance abuse and addiction has witnessed an explosion in important research in the past two decades,” said Dr. David Kupfer, chairman of the DSM-5 Task Force, in a February statement. The changes “reflect the best science in the field and provide new clarity in how to diagnose these disorders.”

Asperger’s syndrome becomes autism spectrum disorder

The proposal to group Asperger’s and other developmental conditions together generated a flurry of comments and concerns. In 2010, when the change was proposed, the Asperger’s Association of New England, a nonprofit organization with more than 3,000 members, wrote a letter to the American Psychiatric Association emphasizing that Asperger’s should remain separate.

But “the revised diagnosis represents a new, more accurate, and medically and scientifically useful way of diagnosing individuals with autism-related disorders,” the national group says on the DSM-5 website.

The work group that recommended the change “believes a single umbrella disorder will improve the diagnoses of ASD without limiting the sensitivity of the criteria, or substantially changing the number of children being diagnosed.”

In a statement on its website Tuesday, the New England association assures its members, “regardless of your diagnosis or label, we will continue to provide a gathering place where members of the Asperger’s community can connect to one another.”

Doctor: Why we’re making changes to autism diagnosis

Being transgender no longer a mental disorder

The DSM-5 eliminates the term “gender identity disorder,” which mental health specialists, along with lesbian, gay, bisexual and transgender activists, had considered stigmatizing. It refers to “gender dysphoria,” which focuses attention only on those who feel distressed by their gender identity.

“I think it’s a significant change,” Jack Drescher, a member of the psychiatric association group that recommended the change, said late last year. “It’s clinically defensible, but it reduces the amount of stigma and harm that existed before.”

Homosexuality was removed from the DSM in 1973, a move he believes changed global views.

Some LGBT activists applauded the change, while others have questioned whether it goes far enough.

Source: http://www.cnn.com/2013/05/21/health/dsm-changes/index.html?hpt=he_c2

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DSM-5 Released Today

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By Ryan Jaslow & Michelle Castillo

Controversial update to psychiatry manual, DSM-5, arrivesThe controversial revision to psychiatrists’ “bible” of diagnostic criteria has finally arrived. The American Psychiatric Association released its fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or dubbed simply as the “DSM-5.”

The manual’s release was coincided with the APA’s annual meeting that kicked off May 18 in San Francisco.

The first major revision to the manual in almost two decades, the new DSM has been met by controversy since reports of proposed changes started to crop up last March.

Doctors often utilize the DSM to diagnose mental health disorders in patients that meet a specific set of criteria.

Among the major changes that garnered the most controversy was dropping Asperger’s syndrome, child disintegrative disorder and pervasive developmental disorder not otherwise specified (PDD), and included them under the blanket diagnosis of autism spectrum disorder.

Revisions were also made to diagnostic criteria for mental health disorders including schizophrenia, bipolar disorder, dissociative identity disorder and depressive disorders.

For example, in the last version of the manual, the 1994 DSM-IV, there was was an exclusion criterion for a major depressive episode that was applied to people with symptoms of depression lasting less than 2 months following the death of a loved one. The DSM-5 removed this after the APA realized since the last version that grief can last up to two years, and bereavement can be a severe psychological stressor that triggers depression, rather than an exception.

Besides worrying some mental health advocates over concerns changes in their diagnosis would affect their abilities to get treatment for state funding, the manual’s release also pitted the government’s National Institute of Mental Health (NIMH) and the American Psychiatric Association (APA),

NIMH director Thomas Insel wrote in a statement in early May that the NIMH felt the proposed definitions for psychiatric disorders were too broad and ignore smaller disorders that were lumped in with a larger diagnosis.

“The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever,” he wrote.

The government agency said it would use a different classification system, the Research Domain Criteria (RDoC) project, instead for its studies.

The NIH and APA released a joint statement on May 13, saying that “patients, families, and insurers can be confident that effective treatments are available and that the DSM is the key resource for delivering the best available care.” But, the statement also said, “The National Institute of Mental Health (NIMH) has not changed its position on DSM-5.”

A petition was also started by doctors to protest the new DSM.

One vocal critic, Dr. Allen Frances, who co-authored the DSM-IV, told CBS This Morning on Thursday that we are over-treating people in this country who are “basically well” and are “shamefully neglecting” people with mental disorders who are really sick, including one million people in prison with psychiatric disorders. The new manual, he said, is too loose for its diagnoses.

He said the average diagnosis is being given by a primary care doctor in a seven minute visit.

“People who are basically normal are getting all kinds of medicine that they don’t need that makes them worse and it is a terrible drain on the economy,” Frances said.

“I’m very curious to see what happens because as you know there’s kind of this tension between the DSM and some of the new NIMH initiatives,” Dr. James Murrough, an assistant professor of psychiatry and neuroscience at Mount Sinai Hospital in New York City, told CBSNews.com Murrough was not involved in the new DSM, but will be presenting research at the APA meeting this weekend.

He said by now, some psychiatrists had hoped the new DSM would contain more information about scientific tests or scans for psychologists or psychiatrists to help aid their diagnoses. But, he added the new version doesn’t appear to look very different from the last one.

“I think everyone is kind of disappointed that we don’t have that yet,” he said.

More information about the DSM-5 can be found on the APA’s website.

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DSM-5: The End of One-Size-Fits-All Addiction Treatment?

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By Mark Willenbring

DSM-5: The End of One-Size-Fits-All Addiction Treatment?When the dust of debate settles, the new revision’s benefits should be clear: good science, better diagnoses, more individualized care.

Sometime this month, the DSM-5 will replace the DSM-IV as the coin of the realm for diagnosis of mental illnesses, including substance use disorders. Despite the unprecedented criticism that has accompanied the process, the final product’s changes are based on very solid epidemiological research, and they are likely to reduce ambiguity and confusion. But there may be some surprise, too, as received wisdom about the diagnosis and treatment of addiction is turned on its head. Let’s hope that this development will result in a more rational and nuanced approach to addiction.

When the DSM-IV was developed, it appeared that abuse and dependence were two distinct disorders. Substance abuse was defined according to four criteria; dependence, according to seven criteria. In practice, “abuse” was often used to denote a milder form of Substance Use Disorder (SUD); “dependence,” a more severe SUD.

In the case of opioids, “dependence” was confusing because almost anyone on opioid-based painkillers for any length of time develops physiological dependence (they will have withdrawal if they stop suddenly), whereas in the DSM-IV, “dependence” meant “addiction” (pathological, compulsive, harmful use). So pain patients prescribed opioids were mislabeled as opioid “dependent” even though they took their medication as prescribed.

Since then, a considerable body of research has shown that there are not two distinct types of substance misuse, but only one. More important, most DSM-IV “abuse” symptoms develop only in people with severe addiction, while “dependence” symptoms are among the earliest to develop. In the DSM-5, “abuse” and “dependence” are gone. In their place is the single “Substance Use Disorder.”

With alcohol, for example, the earliest and most common problems are “internal” problems, such as going over limits, persistent desire to quit or cut down, and use despite hangover or nausea. The only “abuse” criterion that develops early is drinking and driving, but without a DUI. In the largest study of its kind, the NIAAA Epidemiological Study of Alcohol and Related Conditions (NESARC), 90 percent of people who met criteria for DSM-IV alcohol abuse—but not dependence—did so because of admitting drinking and driving. All other abuse criteria only occurred in people with the most severe and chronic addiction, and then late in the game.

In fact, legal problems occur so infrequently that this criterion was dropped from theDSM-5. This may come as a surprise to people working in the treatment industry because legal problems are the most common reason people seek treatment in rehab. But only about 12 percent of people with DSM-IV alcohol dependence ever seek specialty treatment, which suggests that the rest—who are not in treatment—have less severe disorders. People in rehab or AA are to alcohol use disorder what asthmatics on a ventilator in the ICU are to people with asthma: the most severe, treatment-refractory disorders as well as the most co-morbid psychiatric and medical problems. We’ve made a large error by assuming that everyone in the community who meets the criteria for a substance disorder has exactly the same disease as people in rehab or AA.

Read more @ http://www.psmag.com/health/dsm-5-the-end-of-one-size-fits-all-treatment-57193/

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Autism Society Responds to Approved DSM-5 Autism Definition

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Autism Society Responds to Approved DSM-5 Autism DefinitionThe American Psychiatric Association (APA) approved a fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), signing off on a sweeping change to the definition of autism.

The DSM-5 eliminates autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder (not otherwise specified) by dissolving them into one diagnosis called autism spectrum disorder. According to the APA, this represents an effort to more accurately diagnose all individuals showing the signs of autism.

The DSM-5 is important because it provides the diagnostic labels that governments, insurance companies, schools and other institutions use to determine the services needed by each individual. The Autism Society, the nation’s largest grassroots autism organization, strongly advocates that individuals with autism spectrum disorder should continue to access their existing services or maintain their waiting list positions if a diagnosis changes under the DSM-5.

The Autism Society has been very involved throughout this process. We have submitted written comments to the APA advising that changes must not affect the services individuals receive. We have been invited to discuss these upcoming changes with the APA and will continue to represent the rights of individuals with autism–advocating for the protection of services. The Autism Society hosted a keynote session on the DSM-5 at its national conference last July, during which APA working group member Dr. Bryan King explained the need to make autism diagnosis more reliable and valid from person to person and place to place.

Here are a few important points the Autism Society believes all individuals affected by autism should know:

  • The specific diagnoses that are considered Pervasive Developmental Disorders are all quite complex. According to many clinicians, diagnosis of co-morbid conditions occurs too frequently because the definition of autism in the DSM-5 is too long and too complicated.
  • The APA reports that it did not find significant data to differentiate a diagnosis of Asperger’s Syndrome, PDD-NOS and “high functioning” autism.
  • Broad criteria has made it more difficult to grasp an already complex disorder that manifests itself differently person to person.
  • A lack of clinical clarity can also lead to particular populations (females, minorities, and those from low income families) from being properly evaluated, resulting in misdiagnosis and improper treatment.

 

Read more: http://www.autism-society.org/news/autism-society-responds-to-3.html

Final DSM 5 Approved by American Psychiatric Association

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Final DSM 5 Approved by American Psychiatric AssociationYesterday, the board of trustees of the American Psychiatric Association (APA) approved a set of updates, revisions and changes to the reference manual used to diagnose mental disorders. The revision of the manual, called the Diagnostic and Statistical Manual of Mental Disorders and abbreviated as the DSM, is the first significant update in nearly two decades.

Disorders that will be in the new DSM-5 — but only in Section 3, a category of disorders needing further research — include: Attenuated psychosis syndrome, Internet use gaming disorder, Non-suicidal self-injury, and Suicidal behavioral disorder. Section 3 disorders generally won’t be reimbursed by insurance companies for treatment, since they are still undergoing research and revision to their criteria.

So here’s a list of the major updates…

Overall Changes to the DSM

According to the American Psychiatric Association’s statement, there are two major changes to the overall DSM — the dumping of the multiaxial system, and rearranging the chapter order of disorders. Most clinicians only paid attention to Axis I and II, so it’s no surprise the Axis system was never a big hit. The current chapter order has always been a bit of a mystery to most clinicians, so it’s good to know there’s some thought going into the new order of chapters.

Chapter order:

DSM-5’s 20 chapters will be restructured based on disorders’ apparent relatedness to one another, as reflected by similarities in disorders’ underlying vulnerabilities and symptom characteristics.

The changes will align DSM-5 with the World Health Organization’s (WHO) International Classification of Diseases, eleventh edition (ICD-11) and are expected to facilitate improved communication and common use of diagnoses across disorders within chapters.

Removal of multiaxial system:

DSM-5 will move to a nonaxial documentation of diagnosis, combining the former Axes I, II, and III, with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).

Specific Disorders

Autistic disorders will undergo a reshuffling and renaming:

“[Autism] criteria will incorporate several diagnoses from DSM-IV including autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder (not otherwise specified) into the diagnosis of autism spectrum disorder for DSM-5 to help more accurately and consistently diagnose children with autism,” according to an APA statement Saturday.

The rest of this update comes from the APA’s news release on the changes:

Binge eating disorder will be moved from DSM-IV’s Appendix B: Criteria Sets and Axes Provided for Further Study to DSM-5 Section 2. The change is intended to better represent the symptoms and behaviors of people with this condition.

This means binge eating disorder is now a real, recognized mental disorder.

Disruptive mood dysregulation disorder will be included in DSM-5 to diagnose children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year.

The diagnosis is intended to address concerns about potential over-diagnosis and overtreatment of bipolar disorder in children. Will children now stop being diagnosed with bipolar disorder, which has been a recurring concern among many clinicians and researchers? We will see.

Excoriation (skin-picking) disorder is new to DSM-5 and will be included in the Obsessive-Compulsive and Related Disorders chapter.

Hoarding disorder is new to DSM-5.

Its addition to DSM is supported by extensive scientific research on this disorder. This disorder will help characterize people with persistent difficulty discarding or parting with possessions, regardless of their actual value. The behavior usually has harmful effects — emotional, physical, social, financial and even legal — for a hoarder and family members.

Pedophilic disorder criteria will remain unchanged from DSM-IV, but the disorder name will be revised from pedophilia to pedophilic disorder.

Personality disorders:

DSM-5 will maintain the categorical model and criteria for the 10 personality disorders included in DSM-IV and will include the new trait-specific methodology in a separate area of Section 3 to encourage further study how this could be used to diagnose personality disorders in clinical practice.

Posttraumatic stress disorder (PTSD) will be included in a new chapter in DSM-5 on Trauma- and Stressor-Related Disorders.

DSM-5 pays more attention to the behavioral symptoms that accompany PTSD and proposes four distinct diagnostic clusters instead of three. PTSD will also be more developmentally sensitive for children and adolescents.

Removal of bereavement exclusion:

The exclusion criterion in DSM-IV applied to people experiencing depressive symptoms lasting less than two months following the death of a loved one has been removed and replaced by several notes within the text delineating the differences between grief and depression. This reflects the recognition that bereavement is a severe psychosocial stressor that can precipitate a major depressive episode beginning soon after the loss of a loved one.

Specific learning disorder broadens the DSM-IV criteria to represent distinct disorders which interfere with the acquisition and use of one or more of the following academic skills: oral language, reading, written language, or mathematics.

Substance use disorder will combine the DSM-IV categories of substance abuse and
substance dependence. In this one overarching disorder, the criteria have not only been combined, but strengthened. Previous substance abuse criteria required only one symptom while the DSM-5’s mild substance use disorder requires two to three symptoms.

The APA board of trustees also outright rejected some new disorder ideas. The following disorders won’t appear anywhere in the new DSM-5:

  • Anxious depression
  • Hypersexual disorder
  • Parental alienation syndrome
  • Sensory processing disorder

Although clinicians are “treating” these concerns, the board of trustees felt like there wasn’t even enough research to consider putting them in Section 3 of the new DSM (disorders needing further research).

So there you have it. What do you think about these final decisions for the DSM-5?

 

Read the full list of changes from the APA: American Psychiatric Association Board of Trustees Approves DSM-5 (PDF)

Read the full article: Psychiatric association approves changes to diagnostic manual

Source: http://psychcentral.com/blog/archives/2012/12/02/final-dsm-5-approved-by-american-psychiatric-association/

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Should Sexual Addiction Become A Legitimate Mental Health Diagnosis?

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By ROBERT WEISS LCSW, CSAT-S

Is Sex Addiction Real?

Should Sexual Addiction Become A Legitimate Mental Health Diagnosis?There will always be controversy – as there should be – when any form of inherently healthy human behavior such as eating, sleeping, or sex is clinically designated as pathological. And while the power to “label” must always be carefully wielded to avoid turning social, religious, or moral judgments into diagnoses (as was homosexuality in the DSM-I and DSM-II), equal care must be taken to not avoid researching and creating diagnostic criteria for healthy behaviors when they go awry due to underlying psychological deficits and trauma.

Pre-Internet sexual addiction research in the 1980s suggested that approximately 3 to 5 percent of the adult population struggled with some form of addictive sexual behavior. Those studied were a self-selected treatment group, mostly male, who complained of being “hooked” on magazine and video porn, multiple affairs, prostitution, old-fashioned phone sex, and similar behaviors.

More recent studies indicate that sexual addiction is both escalating and simultaneously becoming more evenly distributed among men and women. This escalation in problem sexual behavior appears to be directly related to the increasingly high-speed Internet access to both intensely stimulating graphic pornography and anonymous sexual partnering.

Today these connections are furnished not only through the use of home and laptop computers, but also via smart-phones and the related geo-locating mobile devices we now carry in our pockets and briefcases.

Lamentably, at the very same time that sexual addiction disorder began its technology generated escalation, the American Psychiatric Association (APA) backed away from the provision of either a diagnostic indicator or a workable diagnosis. Consequently, the past 25 years have wrought a somewhat anguished and inconsistent history in the attempts of the psychiatric, addiction, and mental health communities to accurately label and distinguish the problem of excessive adult consensual sexual behavior.

Today, American outpatient psychotherapists and addiction counselors are reporting a marked increase in the number of clients seeking help with self-reported crises related to problems like “I find myself disappearing for multiple hours daily into online porn” or “I feel lost on a never-ending treadmill of anonymous sexual hook-ups and affairs,” not to mention the tens of thousands who daily struggle with the dopamine-fueled nightmare combination of stimulant (meth/cocaine) abuse fused with intensely problematic sexual behavior patterns.

It would seem that these clinicians and clients would benefit greatly from the guidance the APA and DSM might offer them, but does not currently provide.

Read more: http://blogs.psychcentral.com/sex/2012/04/hypersexualitydisorder/

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DSM-5 Critics Pump Up the Volume

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By John Gever, Senior Editor, MedPage Today

Not Diseases, but Categories of SufferingWith crunch time looming for the ongoing revision of the psychiatry profession’s diagnostic manual, critics hoping to stop what they see as destructive changes are taking their campaign to the consumer media.

In early February, British psychologists and psychiatrists unhappy with proposed changes in the fifth edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders — the DSM-5, in its forthcoming incarnation — staged a successful press conference in London, which generated news coverage around the world.

Meanwhile, the most prominent U.S.-based critic of DSM-5, Allen Frances, MD — chairman of the task force that developed the fourth DSM edition in 1994 — has become a regular contributor to the popular Huffington Post website. Last week, he suggested there that the government should force the APA to abandon some of the proposed changes.

And the explosion in social media has allowed other, less well-connected mental health professionals and interested laypeople to create their own platforms for airing concerns about DSM-5 — starting websites and writing comments on others.

At least in part, the rising furor is driven by the DSM-5 revision schedule. The APA has committed to releasing the final version at its May 2013 meeting. Its internal process for ratifying it requires that it be in essentially final form this winter.

Thus, only a few months remain for critics to sway the DSM-5 leadership.

When Does Grief Become Depression?

DSM-5 Critics Pump Up the VolumeMost of the criticism has focused on a few of the many dozens of changes that the DSM-5 working groups have proposed. These include eliminating the so-called bereavement exclusion in diagnosing major depression and adding new diagnoses for people with mild psychotic-like symptoms and problem child behaviors such as severe, repetitive tantrums.

The complaints have a common theme: that the DSM-5 will medicalize — and therefore stigmatize — normal human behaviors.

At the London press conference, for example, psychiatrist Nick Craddock, director of the Welsh National Centre for Mental Health in the U.K., argued that removing the bereavement exclusion would have such an effect.

Under DSM-IV criteria, someone who has lost a loved one can be diagnosed with major depression only if depression symptoms last longer than two months or if they include features not typical of normal grief, such as suicidal ideation.

The proposals for DSM-5 would drop this caveat, allowing for diagnosis of major depression two weeks after a loved one’s death.

According to the DSM-5 working group on depressive disorders, there is no evidence to justify an exclusion for grief but not for other stressors such as divorce, sudden physical disability, or losing one’s home or job.

Defenders of the proposal have also argued that individuals with normal grief may benefit from counseling, which may not be covered by insurance without a DSM-sanctioned diagnosis.

Craddock agreed, but countered that such individuals “did not need a label saying they had a mental illness.”

Similar complaints have been leveled at the proposed new diagnosis of attenuated psychosis syndrome. Its proponents intended it to cover people with persistent but mild hallucinatory symptoms and disturbed thinking — mild enough that the individuals recognize that they aren’t real, but serious enough to find the symptoms bothersome.

In a commentary published in the Feb. 18 issue of The Lancet, two researchers said it would be “premature” to include the syndrome in the DSM.

Paolo Fusar-Poli, MD, of King’s College London, and Alison R. Yung, PhD, of the University of Melbourne in Australia, said that, from the evidence so far, the population likely to receive the diagnosis “is heterogeneous in presentation, clinical needs, and outcome” — and thus too ill-defined without more research and additional diagnostic criteria.

‘Shrinking the Pool of Normality’

Shrinking the Pool of NormalityOne British psychologist, referring to the DSM-5 as a whole, told the Guardian newspaper that its proposals “are likely to shrink the pool of normality to a puddle.”

They also allege that, by expanding the number of people potentially qualifying for a psychiatric diagnosis, DSM-5 will inevitably increase the number treated with drugs.

Another of the speakers at the London press conference, David Pilgrim, of the University of Central Lancashire in Preston, England, called it “hard to avoid the conclusion that DSM-5 will help the interests of the drug companies.”

Former New England Journal of Medicine editor Marcia Angell, MD, noted last year in the New York Review of Books that more than half of DSM-5 working group members had “significant industry interests.”

Frances, too, has written that the DSM-5 will be a “bonanza for the pharmaceutical industry.” But most of his criticisms, which he took public in 2009, have focused on the revision process.

He has been especially concerned with delays in the process — the APA had originally scheduled publication of DSM-5 for this May, but decided in 2009 to push it back one year — and what he believes has been a resulting rush to deliver a final product.

He has repeatedly called on the APA to abandon the revision in its current form. Recently he argued that the Obama administration’s decision to delay implementation of the ICD-10 classification system in the U.S. undercut the APA’s arguments for the May 2013 deadline for DSM-5.

DSM-5 Leaders Stand Their Ground

In a conversation with MedPage Today, APA President John Oldham, MD, and DSM-5 task force chairman David Kupfer, MD, defended their handling of the revision and argued that many of the criticisms were off-base.

For starters, Kupfer said, the proposed revisions were still open to change or abandonment. The DSM-5 will assume its near-final form in June or July, he said — meaning that the APA’s annual meeting in May would provide another forum to debate the changes.

“[The proposals] are still open to revision,” he said. “The door is still very much open.”

Oldham said he was satisfied with the process so far. “It’s an enormously long, and difficult, and challenging thing to do,” he said. “We’re not going to get it perfect. I don’t think anybody could. I don’t think any previous edition could.”

Oldham and Kupfer also argued in favor of removing the bereavement exclusion from the depression criteria.

Said Kupfer, “If patients are suffering not from normal sadness or grief, but are suffering from a severity of symptoms that constitute clinical depression, and need intervention, and they want help, that they should not be prevented from getting the appropriate care that they need because somebody tells them that, well, this is what everybody has when they have a loss.”

Oldham noted that extreme sadness can be triggered by any number of events — natural disasters, physical disability, job losses — yet the DSM-IV created an exclusion only for “bereavement.”

He also pointed out that there are “ranges of heritable risk for major depression” — suggesting that depression may in some sense be normal, yet deserving treatment nonetheless.

The DSM’s overarching purpose, Oldham said, is to enable “patients who need treatment [to] get it.”

Kupfer conceded that field trials of the revised criteria, by design, were not testing whether the changes would increase or decrease the number of people receiving a particular diagnosis. As a result, the critics’ worries won’t be refuted or confirmed until after the revisions go into effect.

“We won’t get 100% consensus on all the proposals,” Oldham said. “That would be totally unrealistic. But I personally think it’s been a thorough and careful process. We’re going to have disagreement. That’s going to happen.”

Source: http://www.medpagetoday.com/Psychiatry/DSM-5/31416

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Possible DSM Changes Spark Controversy

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By Rick Nauert, PhD – PHD Senior News Editor

Possible DSM Changes Spark ControversyProposed revisions to the Diagnostic and Statistical Manual of Mental Disorders (DSM), the fat text used to help identify and categorize mental illness, are not sitting well with many mental health professionals and the public.

Suggested changes to the definitions of autism spectrum disorders and depression, among others, are eliciting great concerns. And experts say there are larger concerns about the DSM as a whole.

“Almost no one likes the DSM, but no one knows what to do about it,” said University of Michigan psychiatrist Dr. Randolph Nesse.

The current round of revisions is the fifth since the DSM was originally published by the American Psychiatric Association in 1952.

Nesse and University of Cape Town psychiatrist Dr. Dan Stein combined for an article in the current issue of BMC Medicine titled “Towards a genuinely medical model for psychiatric nosology.”

The article provides a candid appraisal of the difficulty of categorizing mental disorders that the authors expect will not make a lot of their colleagues happy.

“The problem is not the DSM criteria,” Nesse said. “The problem is that the untidy nature of mental disorders is at odds with our wish for a neat, clean classification system.”

The proposed abolition of the grief exclusion, for example, in diagnosing major depression is just one example of a push to define psychiatric disorders according to their causes and brain pathology.

“A huge debate over when depression is abnormal seems likely to be resolved by removing the so-called ‘grief exclusion,’” Nesse said. “At the moment, depression is not diagnosed in the two months after loss of a loved one.

“The result of this proposed change would be that people experiencing normal grief will receive a diagnosis of major depression. Doing this would increase consistency in diagnosing depression, but at the cost of common sense. It’s clear that bereavement is not a mental disorder.”

Nesse and Stein point out that the rest of medicine recognizes many disorders that do not have specific causes.

“Conditions such as congestive heart failure can have many causes,” Nesse said. “This doesn’t bother physicians because they understand what the heart is for, and how it works to circulate blood.”

Furthermore, he said, physicians recognize symptoms such as fever and pain as useful responses, not diseases.

“These symptoms can be pathological when they’re expressed for no good reason, but before considering that possibility, physicians look carefully for some abnormality arousing such symptoms,” Nesse said. “Likewise, the utility of anxiety is recognized, but its disorders are defined by the number and intensity of symptoms, irrespective of the cause.

“It’s vital to recognize that emotions serve functions in the same way that pain, cough and fever do, and that strong negative emotions can be normal responses to challenging or anxiety-provoking situations.”

Instead of specific diseases with specific causes, many mental problems are “somewhat heterogeneous overlapping syndromes that can have multiple causes,” Nesse said.

“Most are not distinct species like birds or flowers. They are more like different plant communities, each with a typical collection of species. Distinguishing tundra from alpine meadow, arboreal forest and Sonoran desert is useful, even though the categories are not entirely homogenous and distinct.”

Source: http://psychcentral.com/news/2012/02/16/possible-dsm-changes-spark-controversy/34909.html

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