Advance praise for DSM-5
/Today, 24 March 2013, there is an interesting set of letters on the Opinion Pages of the New York Times Sunday Review. This was followed up on 29 March by an article in the Psychiatric Times by Dr Pies, who had opened the first series.
Included in the responses and comments are some of the many people who are criticising and attacking DSM-5 ahead of its publication, and are doing so based on the limited information that has been released. I thought I could just as well say some positive things about DSM-5, based on the same kind of speculation about what the final decisions by the American Psychiatric Association in last December (2012) have been.
- The diagnosis of Bipolar for children has been abolished. In its place they have created a completely new diagnostic category, Disruptive Mood Dysregulation Disorder (DMDD). There is now a substitute amount of indignation about DMDD having many things wrong with it, but overall taking it away from all the things that went with child bipolar is in my view a big achievement.
- The system of personality disorders has not been changed materially. The Axis I / Axis II distinction will, I believe, be abandoned. Broadly speaking the idea of personality disorders has stood the test of time. Partly because of problems with the implementation for DSM-IV, it has not stuck completely. But the attempts at simplification that were tried didn't get enough assent either. So this was a reasonable compromise. And removing the Axis II "gimmick" seems very sensible to me.
- The dementias and amnesia have been combined in a larger overall category of "neurocognitive disorders", with less emphasis on the individual dementia subcategories. This seems overall exactly the right direction. The distinctions between the dementias still cannot be made reliably, as time and again autopsy reveals that the guessed diagnosis was the wrong one. And it probably makes less difference in treatment than was held at times. Adding amnesia in follows the best views of professional carers. These changes, and the dimensionality of minor and major all seem to be helpful improvements that will support cares and professionals in the field of mental health for older people that is bound to see an enormous growth in the coming decades.
- A new chapter has been created for disorders caused by trauma or "stressors", including PTSD. Unlike many, I don't have a problem with these problems being included in the DSM. When you have a physical disease you are ill, even when it is flu or a cold. So when there are problems in living, and there is a "mental" aspect to it, it is OK to be able to categorize and count it. By putting these stress-caused disorders in a separate category, it is made even clearer that these are problems that are fully externally caused, by the trauma, abuse or other stressors undergone. That seems a helpful move.
- Autism and Asperger's syndrome have been combined into an overall category of Autism spectrum disorders. I believe this had in practice already been taking place to some extent. To see autism proper and Asperger's as similar but on a scale of severity, rather than as distinct syndromes, seems a plausible way of seeing these problems. Again, I can't get warm or cold about the issue whether the combined somewhat simplified and rationalized criteria would lead to slightly more or slightly fewer people diagnosed. Unlike the general criticism of diagnostic systems, in the case of this diagnosis people seem to rather have the diagnosis than not have it. Still, that should not be the driver of formulating the criteria.
- The field of disorders related with sexuality, gender and "perverse" or "paraphilic" / "paraphiliac" behaviours has been somewhat modified, but overall appears not to have been made worse than it was. I don't have enough information to be certain of how it is going to look. At least, as far as I know, "paraphilic coercive disorder" - in my opinion equivalent to "rape as a mental disorder" - seems to have been ditched. And hebephilia as a designation for attraction to "early pubescent" children has not made it either. I can't find out if they have left in "sex addiction" or taken it out. I can only hope the latter.
- Account has been taken of the dimensional way of looking at most "mental" problems, without going all the way to a purely or mainly dimensional system. This was in response to a long campaign to move in this direction. The direction is right, but given the overall purpose of having a diagnostic system in the first place, it seems that there always has to be a categorical side to it, in order to use the system for statistical and research purposes. What they are trying to do seems the best available compromise, and is in response to widely held professional views.
- As regards disorders related to the body and the somatisation of distress, I believe that the APA have combined somatoform disorders, hypochondriasis, pain disorder, and factitious disorder into one new overall category of "somatic symptom disorder". This combination seems good. There is a small outcry that in this case the disorder might "catch" too many people. I think the practical implementation will deal with that. It is unclear what consequences, positive or negative, will be implied by getting the diagnosis. Unlike some other categories, it is not likely to trigger a particular type of medication. This also implies that at least this change cannot be a consequence of pharma industry lobbying (or have I missed something?)
- Binge-eating disorder has been formally added. It was already being used extensively, as it is accepted by most eating disorder specialists as "existing" in a clear way, different from anorexia nervosa and from bulimia, and distinct enough to require a better category than "other eating disorders". A straightforward positive change.
I think I am as able as the next person to write a list of the changes and non-changes in DSM-5 compared with DSM-IV-TR that I dislike and should not have been selected. But I believe that there are already enough people who do that, and was in search of a bit of balance.
Is DSM-5 "a very bad thing"?
Do I think that DSM-5 should not exist? Do I think it could be abolished? Do I think the same about the WHO's ICD-10 (and soon ICD-11) systems and several alternative classification systems that have been and are being proposed? Do I think that a world without diagnoses, classifications and labels would be a better world for "people with somehow "mental health"-related problems" (for want of a better expression)? These are difficult and serious questions, but I will deal with them, on the limited scale allowed by the blogging conventions, in a separate blog.