Updating the Bible of Mental Health

One of the major stories in my slice of science for the past five years has been the updating of the Diagnostic and Statistical Manual of Mental Disorders. Currently out is the DSM-IV-TR (text revision), which has had no updates to diagnostic criteria since 1994. Recently, the board of trustees of the American Psychiatric Association met and approved the revised DSM. The DSM-5 is scheduled to come out in May of 2013, coinciding with the APA’s annual conference.

Although change and progress are at the core of any scientific endeavor, a number of the changes that seem set to appear in the DSM-5 have stirred enormous controversy. In fact, there is even serious talk of ignoring it wholesale with the psychology community (for a sterling response to the DSM-5, see the British Psychological Society). While I think that some of the changes are quite good and well-backed by the evidence, others appear to be driven primarily by poor science and/or a too comfy relationship between Big Pharma and psychiatry.

My area of specialty, the anxiety disorders, is changing in some ways that are positive (separating agoraphobia and panic disorder into distinct disorders) and in some ways that I do not think are properly backed up by the data (removing OCD from the anxiety disorders and creating an OC Spectrum category that includes trichotillomania, body dysmorphic disorder, and others). But these are really arguments that will not negatively impact people’s daily lives (although there does seem to be a widening of the definition of Generalized Anxiety Disorder and Posttraumatic Stress Disorder that is a bit troubling).

On the other hand are some of the very controversial revisions that have been proposed. These seem to fall into two categories: disliked by the public but backed by the science and unknown by the public and not backed by the science. Dr. Allen Frances, the head of the group that birthed the DSM-IV, has been very vocal with his concerns over what he calls a

“…deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound. My best advice to clinicians, to the press, and to the general public – be skeptical and don’t follow DSM 5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication.”

(Dr. Frances’ list of critiques can be found here and the New York Times has been doing a bang-up job on it’s coverage.)

One of the loudest voices calling for a reexamination of proposed changes has been in the autism community. In the DSM-5, the separate diagnoses of autistic disorder, Asperger’s disorder, and Pervasive Developmental Delay (not otherwise specificed) are all being collapsed into a single, continuous “Autism Spectrum Disorder.” The personality disorders are also being massively reorganized into a less dichotomous, more continuum-based group. Based on my reading of the data, these are both solid decisions that (although they may cause confusion at first) are more reflective of reality as best we can tell.

A number of other changes, though…ugh. From a new category for what could best be described as temper tantrums (Disruptive Mood Dysregulation Disorder), to the medicalization of normal grieving for a loss (and saying it is instead major depression), to a disorder for those who overeat only occasionally, there looks to be a number of problems ahead for psychiatry’s public image.

I suppose we will just have to wait and see what the future holds…and hope that it won’t be another 19 years before some of these categories are revisited.