DSM Revisions Proposed

March 11, 2010

Author: Catherine M. Callery (Kate) | Louise M. Tarantino

The Diagnostic Statistical Manual of Mental Disorders - or DSM - is slated for some major revisions to psychiatric diagnoses when the fifth edition is published in 2013 (DSM 5).  The American Psychiatric Association (APA), which publishes what is often considered the “Bible” of the psychiatric profession, has for the first time unveiled proposed revisions on February 9, 2010, and invited the public to comment by April 30, 2010.  The recommendations are posted online at DSM5.org.

Last revised in 1993 (DSM-IV-Text Revised), the encyclopedia of mental disorders was described by the New York Times in a February 10, 2010 article as determining “where society draws the line between normal and not normal, between eccentricity and illness, between self-indulgence and self-destruction – and, by extension, when and how patients should be treated.” Over the years, the DSM has generated controversy and criticism for what it defines as a medical disorder and what it doesn’t.  For example, homosexuality used to be listed as a disorder. The proposed revisions are already stirring up controversies of their own.

Among the proposed changes that have made the news include the APA’s recommendation to made Asperger’s Disorder part of the autism spectrum disorder as opposed to a separate diagnosis.  The autism spectrum disorder would incorporate autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified.  But according to Michael John Carley, executive director of the Global and Regional Asperger Syndrome Partnership in New York and author of Asperger's From the Inside Out, the change may be hard for some people with Asperger’s to accept. Carley, who was diagnosed with Asperger’s years ago, told National Public Radio’s Jon Hamilton in an interview aired on February 11, 2010, that “I personally am probably going to have a very hard time calling myself autistic.”  Many people with Asperger’s take pride in a diagnosis that probably describes some major historical figures, including Albert Einstein and Thomas Edison.

Changes such as the one proposed for the Asperger’s diagnosis can have implications beyond just the diagnosis.  According to Dr. Michael First, a professor of psychiatry who was involved in the fourth edition of the DSM but the fifth, told the New York Times that any change made to the DSM “has huge implications not only for psychiatry but for pharmaceutical marketing, research, for the legal system, for who’s considered to be normal or not, for who’s considered disabled.”  For example, Melinda Bird, senior counsel with the advocacy group Disability Rights California, told NPR’s Larry Abramson that the incorporation of Asperger’s into the autism spectrum could make it easier for children to get special education services.  She says California school districts regularly question whether kids with Asperger’s need special education services because they are often very verbal and bright.  The new proposed guidelines could ease that confusion.  On the other hand, some educators fear that losing the label will deprive them of an important tool that helped them understand what certain children need.

Another proposed revision with wide-spread implications involves the treatment of bipolar disorders in children.  According to some reports, the number of children diagnosed with bipolar disorder has increased 4,000 percent since the mid-1990s. This increase in diagnoses and the increased use of antipsychotic medications in young children has not been without controversy in the medical and psychiatric communities, including disagreement of whether some children should be saddled with such a serious diagnosis for life.  [For a fascinating account of the advent of the increase in the diagnosis in children and the more recent backlash, see http://www.npr.org/templates/story/story.php?storyId=123544191.  And for a report of a recent study concluding that children on Medicaid are far more likely than children with private insurance to be prescribed antipsychotic medications, see http://www.nytimes.com/2009/12/12/health/12medicaid.html?pagewanted=1&_r=2&sq=psychotic%20drugs&st=cse&scp=1].

In response, the APA has proposed a new diagnosis: Temper Dysregulation Disorder. According to the APA, the new proposed disorder is not necessarily a lifelong condition and can only be diagnosed in children over six years of age.

DSM 5 would also change the terminology and definitions for mental retardation.  The new diagnosis of “intellectual disability” would be tied less to IQ scores and more to functionality, although still retaining the reference to IQ scores of 70 or below.  Among other things, the APA hopes to avoid problems with inaccuracy of testing.  Other new terms entering the psychiatric lexicon would include “binge eating disorders” and “hypersexuality.”  And “addiction” would become “substance abuse.”

The drafters are also recommending the creation of a scale of severity for every disorder – or the “dimensional assessment approach.”  The emphasis on the scale represents a move away from the checklist approach taken previously in rendering diagnoses.  Currently, for example, the diagnosis of depression requires five of nine criteria.  Under the proposed system, a patient meeting only four criteria might be eligible for the diagnosis, depending on the severity of his or her symptoms.  The APA explains its new approach at http://www.dsm5.org/ProposedRevisions/Pages/Cross-CuttingDimensionalAssessmentinDSM-5.aspx.  For more on this dimensional assessment approach, see http://www.npr.org/templates/story/story.php?storyId=123531958.

Finally, for those GAF aficionados out there, the advisory committee is proposing changes to DSM’s current multi-axial approach.  Axes I, II, and III would be collapsed into one axis that contains all psychiatric and general medical diagnoses, bringing the DSM-5 in closer accord with the single-axis approach used by the international community in the World Health Organization’s (WHO) International Classification of Diseases (ICD).  A subgroup is examining Axis IV to determine if the codes in the 10th edition of the ICD should be adopted. Regarding Axis V – or the Global Assessment of Functioning (GAF), the Impairment and Disability Study Group is considering ways in which disability and distress can be better assessed in DSM-5.  It is recommending that DSM-5 more closely follow the concepts outlines in the WHO International Family of Classifications, in which disorders and their associated disabilities are conceptually distinct and assessed separately.

The APA has made its proposals available to the public in an easy to read format at http://www.dsm5.org.  You can readily check to see if your favorite diagnosis is up for revision or not, compare the proposed revisions with the current DSM, and read the APA’s rationale for its proposed changes.  The APA will also be accepting public comments on the proposals through April 20, 2010.

Remember that any changes won’t be finalized until 2013 - and given that SSA’s mental impairment listings currently track the DSM-III, don’t hold your breath for seeing the new revisions incorporated into the listings any time soon!