DSM-5 Changes – A closer look at its implications

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The American Psychiatric Association’s fifth edition of its Diagnostic and Statistical Manual of Mental Disorders was released this past May, but the long-term conversation around DSM-5 changes and its impact on diagnosis and care has yet to die down.

The DSM-IV, the new manual’s predecessor, was introduced in 1994, and since then new insights into mental and behavioral health have emerged. According to Thomas Insel, M.D., the director of the National Institute of Mental Health, these changes specifically included diagnostic categories, including autism spectrum and mood disorders.

As Insel wrote in late April, shortly before DSM-5 debuted, while the most recent manual is often called “the Bible” for the field of psychopathology, in reality its service is closer to that of a dictionary. The DSM lays out a set of labels in an orderly fashion and defines each. It creates a standard within the industry. But what if that dictionary didn’t always match the right definition to the right word?

Insel pointed out that health conditions like ischemic heart disease, lymphoma and AIDS have concrete medical definitions constructed based on laboratory analysis. DSM diagnoses are by nature more ephemeral, usually based on clinical consensus based around perceived symptoms. As Insel put it, in the last half century the medical community has stopped treating based on symptoms – except when it comes to mental health.

This is where the industry bible flounders, however. Based on symptomatic-diagnosis without biological backing, Insel and others were calling the DSM-V outdated before it even debuted. In fact, the NIMH purposefully set up its own project – called Research Domain Criteria – which will attempt to change the nature of diagnoses in mental and behavioral health today, with a focus on genetics and imaging.

The public implications
The NIMH’s project goal isn’t to make diagnosis easier, however. It’s striving for accuracy, where the DSM-5 seems to settle on broader strokes. In fact, as reported by a story in Slate, according to the DSM-5, the odds are greater than 50 percent that any average individual will have a mental disorder in his or her lifetime.

Once controversial decision pioneered in the DSM-5 was to eliminate a number of autism spectrum diagnoses, including Asperger’s syndrome. These are now grouped under the single category of autism spectrum disorder. According to Slate, the reactions before and immediately following the release were mixed, but none of them good.

More than 8,000 people signed a petition from the Global and Regional Asperger’s Syndrome Partnership, and 5,400 signed a second petition sponsored by the Asperger’s Association of New England, among other efforts.

The argument against the change may be rooted in the same place that drove the NIMH to turn away from the DSM-5. Consider the argument given by Simon Baron-Cohen, Ph.D., director of the Autism Research Center at Cambridge University, in his 2009 editorial for The New York Times. Here, he outlined that there could be a biological difference between classic autism and Asperger’s. In fact, he referenced a study he and a colleague recently published, which had identified 14 genes associated specifically with Asperger’s.

And it’s not just the potential genetics that need more examination, Baron-Cohen wrote. The DSM-5 changes mean an altered diagnosis, which could create confusion in the mental and behavioral health patient population. Furthermore, such sudden changes could disrupt or alter the continuum of care that many patients rely on.

This isn’t even taking into account those patients who may no longer meet requirements for diagnosis. According to a study from researchers at the Child Study Center at the Yale School of Medicine, a potential 75 percent of patients with Asperger’s – not to mention 85 percent with what’s called “pervasive development disorder not otherwise specified,” or PDD-NOS – would fail to qualify.

Future development
The DSM is a constant work in progress, but only time will tell whether the fifth edition presents steps backwards or forwards.

Ian Hacking, a Canadian philosopher with a special interest in science and statistics, reviewed the DSM-V for the Aug. 8, 2013, edition of the London Review of Books. Here, he noted that that the DSM likely had its earliest predecessor in 1844, when the American Psychiatric Association, in the same year it was founded, created a statistical classification system for asylum patients. Then, during World War I, a similar system was incorporated for assessing army recruits, marking what might have been the first time it was used as a diagnostic tool.

The current manual has come a long way, but for clinicians, weathering the newest changes still may be a challenge.

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