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Last chance to comment on psychiatry's controversial diagnostic 'bible'

DSM-IV
CC/Flickr/Richard Masoner/Cyclelicious
The venerable DSM-4 will soon be replaced by the DSM-5

It’s your last chance to give the American Psychiatric Association (APA) your feedback on the upcoming fifth edition of its Diagnostic and Statistical Manual of Mental Orders, or DSM-5.

This long-awaited and highly controversial manual, known as psychiatry’s diagnostic “bible,” is heading into the final stage of its revision process. The latest draft was posted on the APA’s website earlier this week and will be the center of discussion this weekend at the APA’s annual meeting in Philadelphia. Public comment closes June 15, and the final version of the revised manual will be published in May 2013.

As Dr. Allen J. Frances, a psychiatrist who headed the task force that oversaw the last edition of the DSM but who is now a leading critic of DSM-5 and its expanding definitions of mental illnesses, says he breathed a “sign of relief” that two of the most controversial proposals for changes to the DSM had been dropped: “attenuated psychosis syndrome” (or “psychosis risk,” as Frances calls it) and “mixed anxiety depressive disorder.”

“We have dodged bullets on Psychosis Risk and Mixed Anxiety Depression,” he writes in his Psychology Today blog. “Both are now definitely rejected as official DSM-5 diagnoses and instead are being exiled to the appendix.”

A safer place’

Frances is especially pleased about the purging of attenuated psychosis syndrome. “The world is a safer place now that [it] will not be in DSM-5,” he says. “Its rejection saves our kids from the risk of unnecessary exposure to antipsychotic drugs (with their side effects of obesity, diabetes, cardiovascular problems, and shortened life expectancy).”

The problem with the attenuated psychosis syndrome, adds Time reporter Maia Szalavitz in her discussion of the new DSM-5 changes, “is that only 8% of those categorized as ‘high risk’ because they have close relatives with the disorder or have suggestive symptoms actually went on to develop schizophrenia, according to a recent study. Many critics of the new diagnosis feared that it would legitimize the potentially dangerous practice of administering powerful antipsychotic drugs to youths. With every major manufacturer of antipsychotics already paying out hundreds of millions or billions of dollars in fines for mismarketing these medications to youth and the elderly, the problem of overprescribing is already rampant — particularly in vulnerable populations like foster care children.”

The overprescribing of medications is also why Frances and other DSM-5 critics had been so concerned about the vaguely defined “mixed anxiety depressive disorder” category.

Additional controversies

But other DSM-5 controversies remain, which is why a group called Occupy the APA has scheduled a demonstration in Philadelphia on Saturday to coincide with the APA’s annual meeting.

"Much of the rest of DSM-5 is still a mess," writes Frances. "The reliabilities achieved for many of the other disorders are apparently unbelievably low and the writing of the criteria sets is still unacceptably imprecise."

Here are two of those remaining controversies, as described by Szalavitz:

Although some language was changed, the committee still seems determined to include bereavement in the definition of depression, which could allow someone who is going through normal grief after a loss to be diagnosed with major depression. In previous editions of the DSM, bereavement was excluded from the definition: depressive symptoms during grieving were not considered abnormal if they were better explained by the person’s loss and were not extremely prolonged.

Another change that remains is the elimination of the diagnosis of Asperger’s syndrome, which will be subsumed under autism spectrum disorders in the DSM-5. Autism advocates oppose the change because they are concerned that families affected by Asperger’s will lose critical educational and other services. They also contend that the revision will diminish clarity of diagnoses, both for research purposes and personal understanding.

The process is not over

The DSM is an important document for all of us because it’s used by mental health professionals to determine what behavior is “normal” and what isn’t (and, therefore, needs medication or other treatments). If you want to read and comment on the latest DSM-5 draft, you’ll find it on the APA website. You can also follow Scientific American editor Ferris Jabr and his colleague Ingrid Wickelgren over the next few days as they blog about the DSM-related discussions at the APA’s annual meeting.

Many reputations, egos — and dollars — are at stake with the revisions to the DSM-5. More changes to the document are sure to come.

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