DSM-5: Positives and Negatives
The DSM-5 was in development for more than 10 years. Its official release was announced in May, 2013 at the American Psychiatric Association’s annual meeting in San Francisco, California. New diagnoses have been added and others have been amended or combined. Some proposed criteria considered for inclusion stirred up so much public and professional ire they were eventually eliminated from the final draft.
The most noteworthy changes to the manual are concept-driven. The multiaxial system of the previous DSMs has been dropped in favor of a dimensional diagnostic scheme. This new format combines the former axes I, II, and III with separate notations for psychosocial and context factors (formerly axis IV) and disability (formerly axis V). Also, the chapter order is different and other disorders have been grouped.
The furor surrounding the DSM-5’s changes — particularly its additions — has subsided, for the most part as of this writing; but in the first six months subsequent to its release, proponents and opponents of the guide’s changes eagerly held their ground, defending their positions. I’ve conducted my own thorough independent review of the DSM-5, so here’s my take on its positives and negatives:
- DSM-5 has tightened up criteria in the best interest of patients.
- The multiaxial classification system needed to go. Most of us practice professionals used axes I and II all but exclusively.
- Mental retardation is no longer being used as a diagnosis and is being replaced by “Intellectual Disability.” This change comports well with established practices in the field.
- Autistic Disorder is gone as a diagnosis and is replaced by “Autistic Spectrum Disorder.” Also gone is Asperger’s Syndrome. This is a good move because the spectrum concept provides overall better usefulness for the autistic disorders as a group.
- Another positive change is the reorganization of disorders such as Obsessive-Compulsive Disorder and Post-traumatic Stress Disorder. Anxiety is not the root cause of either of these disorders therefore these syndromes have been re-grouped accordingly as a reflection of clinical advancements aided by neuroscience.
- In the schizophrenia arena, the five subtypes (disorganized, catatonic, undifferentiated, etc.) were nixed because they were rightly largely ignored.
- Disruptive Mood Dysregulation Disorder (DMDD). This diagnosis morphed out of the over-diagnosis of Bipolar Disorder in youth, and will serve as a diagnostic dumping ground for children by pathologizing what amounts in many instances to no more than garden variety temper tantrums. We already have Oppositional Defiance to cover for this, and it’s quite adequate. And what’s the chance that a clinician who is intolerant of unruly behavior will be quick to diagnosis this and get paid by an insurance company? This is a mess waiting to happen, is untested and opens another door for medicating kids inappropriately and excessively.
- Minor Neurocognitive Disorder. The certainty with which we can differentiate symptomatic profiles which represent true early warning signs from occasional variability in cognitive performance is problematic. Thus, forgetfulness associated with the aging process will now be at risk for a diagnosis of Minor Neurocognitive Disorder. It’s true that some of these people may be at risk for dementia, but it also could create a pool of false positives for those not at risk for dementia – creating unnecessary anxiety for these people. Also, there is NO effective treatment for MND, so why not wait for the more accurate biological markers for dementia – particularly the Alzheimer’s type – to emerge. I’ll bet that they’ll be available within five years.
- Generalized Anxiety Disorder. This disorder has had shady boundaries since it was first included in the DSM. Now that the duration of symptoms has been reduced from six months to three months it will be harder to distinguish what is truly a chronic disorder from the concerns of everyday life. This will create a sizable new subset of “anxious” people who may be unnecessarily treated with antianxiety medications when all they are experiencing are the ups and downs of living life on life’s terms.
- Bereavement Exclusion. Widespread criticism emanated from the decision to eliminate the so-called bereavement exclusion in which a grieving individual had up to two months after the death of a loved one without being diagnosed with Major Depressive Disorder. This simply did not need to be meddled with. Grief is an absolutely normal human response to loss and shouldn’t be placed on the “clock” so to speak, and any competent clinician wouldn’t miss the presence of major depression — even when occurring during bereavement.
- ADHD. DSM-5 has made the path to diagnosing ADHD easier than it has ever been. According to the Centers for Disease Control and Prevention (CDC), nearly one in five high school age boys in the United States and 11 percent of school-age children have received a diagnosis of ADHD. There has been a 53 percent rise in diagnosis in those ages 4-17 in this past decade alone. DSM-5 allows for symptoms to merely “interfere” with daily activities, rather than cause impairment. Also, the requirement that symptoms appear before age 7 is changed to before age 12. My number one concern here is that since every psychiatric syndrome on earth adversely affects attention in some way, making it easier to go to ADHD means that other potentially important diagnoses may be overlooked.
This edition of the DSM has spurred supporters and detractors to draw battle lines unseen with its predecessors. In a nutshell, supporters claim that DSM-5’s more patient-driven approach better allows for the diagnosis of individuals who would have previously been excluded by previous DSMs. Detractors believe that expanding diagnostic categories — and softening criteria in some instances — will produce a subset of new “patients” who are experiencing little more than the ups and downs associated with the rhythm of life.
Pitching a tent in one camp or the other will never trump the importance of individualizing assessment and diagnosis in every client instance presenting itself to us.
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.