Monthly Archives: July 2013

The DSM-5: A Not-So-Extreme Makeover

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As I write this post, after thirteen years, DSM-IV is-and will forever remain-a great bargain on the discount book rack, as the fifth edition (DSM-5) was released in May 2013.
Before evaluating the specific revisions made to the area of traumatic stress, let’s quickly review the purpose of the DSM and the controversy surrounding this version’s publication. According to the American Psychiatric Association’s website:
“DSM stands for “Diagnostic and Statistical Manual of Mental Disorders” and is published by the American Psychiatric Association, the professional organization representing United States psychiatrists. DSM contains a listing of psychiatric disorders and their corresponding diagnostic codes. Each disorder included in the manual is accompanied by a set of diagnostic criteria and text containing information about the disorder, such as associated features, prevalence, familial patterns, age-, culture- and gender-specific features, and differential diagnosis. … (DSM) provides standard criteria and common language for the classification of mental disorders.” (1)         ~American Psychiatric Association website (www.psychiatry.org)
Due to its “radical changes,” this particular iteration-the manual’s first major revision in nearly 20 years-has been contentious within and outside the field. Reactions range from fear to neutrality to anger and disgust, with many professionals-clinicians and researchers alike-voicing concern and lodging formal complaints, while consumer groups are filing lawsuits. In an article titled, The New Crisis in Confidence in Psychiatric Diagnosis, Allen Frances, MD, chair of the DSM-IV Task Force and one of the new manual’s staunchest critics, suggests that we use the DSM-5 “cautiously, if at all.” Frances summarized the majority of complaints
“The DSM-5…lacked sufficient scientific support and defied clinical common sense. It was prepared without adequate consideration of risk–benefit ratios and the economic cost of expanding the reach of psychiatry just when the field is about to achieve parity within an expanded national insurance system. … I found the DSM-5 process secretive, closed, and disorganized. … Field trials produced reliability results that did not meet historical standards. I believe that the American Psychiatric Association (APA)’s financial conflict of interest, generated by DSM publishing profits needed to fill its budget deficit, led to premature publication of an incompletely tested and poorly edited product. The APA refused a petition for an independent scientific review of the DSM-5 that was endorsed by more than 50 mental health associations (8). Publishing profits trumped public interest.” (2) (Frances, 2013)
Heated arguments will likely continue, but for now, it’s here and some of us have to use it. So let’s review some of the general changes.
Spoiler alert-the first notable change is in the title, right there on the cover. The DSM has converted from Roman numerals to Arabic numbers. Entirely reasonable, as Arabic numbers are less cumbersome, and let’s face it, hardly anyone speaks Roman anymore. Essentially, all future text revisions (prior to the manual’s next complete revision) will have simpler designations, e.g., DSM-5.1, DSM-5.2. DSM-5 Task Force Chair, David Kupfer, M.D., summed up this change: “We used ‘5’ because V.0 and V.1 just don’t look good.”
Further modernizing the manual, some of the more defamatory terminology has been eliminated and some of it replaced. Here are a few examples: Mental retardation is now Intellectual disability; Hypochondriasis is Illness anxiety disorder; The paraphilias are now Paraphilic disorders; and temper tantrums are now Disruptive mood dysregulation disorder.
The DSM-5 has eliminated four of its five axes. Going forward, clinicians will assess criteria solely for psychological disorder(s) and record diagnoses on the last axis standing. No reason for opposition here either, as the five axial diagnostic system wasn’t without problems, however, the majority of my complaints have historically been reserved for “Axis II.”
Good ole’ Axis II. That inexplicable combination of poorly named, yet universally disparaged disorders, including: disorders that developed in childhood, but not mental retardation; personality disorders; and, …wait, what was the other one? Right, mental retardation. That categorical nightmare, peppered with stigmatizing terminology, will not be missed.
The modest changes mentioned above are all well and good, but, I was promised something more. I was led to believe that besides the long-awaited name change for the pejorative diagnosis, Borderline Personality Disorder, we were going to see BIG CHANGES within the Personality Disorders category.
In an article entitled, DSM Section Contains Alternative Model for Evaluation of PD, Mark Moran reported: “John Oldham, M.D., a past APA president and a member of the Work Group on Personality Disorders, told Psychiatric News, ‘From the beginning of the development process for DSM-5, the personality disorders were identified as a place where we needed to move beyond the categorical diagnostic system of discrete disorders in DSM-IV toward a more dimensional system.’’’Scientists and researchers alike recognized the necessity of change. Nick Craddock, Chairperson of the Academic Faculty of the Royal College of Psychiatrists wrote: “We are entering a transitional period of several years during which psychiatry will need to move from using traditional descriptive diagnoses to clinical entities (categories and/or dimensions) that relate more closely to the underlying workings of the brain.” (3, 4) Expounding on its necessity, Oldham wrote: “…The alternative model is intended to move toward a way of diagnosing disorders that fits the patient who comes to the clinician’s office with a variety of presentations, rather than fitting the individual into a preconceived categorical scheme.”
For months I followed along with the workgroup’s process, which held such promise. I watched as a diagnostically and empirically useful alternative model was developed, and according to Oldham, “well received by clinicians and greatly preferred over that in DSM-IV.”
I applauded and enthusiastically awaited the manual’s completion and subsequent publication, because I was sure that this revision would be the one that improved the care of a historically misunderstood and underrepresented personality disordered population, a.k.a., my treatment population.
Change was inevitable. Most assuredly inevitable.