Controversy over DSM-5: new mental health guide

Behind the Headlines

Thursday August 15 2013

The DSM has been dubbed the ‘Bible of Psychiatry’

“Doctors in dispute: What exactly is normal human behaviour?”, wrote The Independent, while The Observer said: “Psychiatrists under fire in mental health battle.”

These headlines focused on a new version of a major guide to mental health that was published in May 2013 amid a storm of controversy and bitter criticism.

Fourteen years in the writing (and according to one psychiatrist, “thick enough to stop a bullet”) the fifth edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders” (DSM-5) has been dubbed “The Psychiatrist’s Bible”.

DSM-5 is an attempt to provide doctors with a much-needed definitive list of all recognised mental health conditions, including their symptoms. But with so many gaps in our understanding of mental health, even attempting to do so is hugely controversial.

There are two main interrelated criticisms of DSM-5:

 

A brief history of the DSM

The DSM was created to enable mental health professionals to communicate using a common diagnostic language. Its forerunner was published in 1917, primarily for gathering statistics across mental hospitals. It had the politically incorrect title Statistical Manual for the Use of Institutions for the Insane and included just 22 diagnoses.

The DSM was first published in 1952 when the US armed forces wanted a guide on the diagnosis of servicemen. There was also an increasing push against the idea of treating people in institutions.

The first version had many concepts and suggestions that would be shocking to today’s mental health professional. Infamously, homosexuality was listed as a "sociopathic personality disorder" and remained so until 1973. Autistic spectrum disorders were also thought to be a type of childhood schizophrenia.

Because our understanding of mental health is evolving, the DSM is periodically updated. In each revision, mental health conditions that are no longer considered valid are removed, while newly defined conditions are added.

Why the DSM-5 is important for the NHS

Although the NHS uses the World Health Organization system of diagnosing mental health conditions called ICD-10 (International Classification of Diseases), the previous version of DSM, (DSM-IV-TR) has a major influence on how mental health is thought about and treated in this country.

 

It helps set research agendas, brings conditions into the public eye and influences clinical guidelines. Previous versions of the DSM were arguably responsible for making certain conditions better known in the UK, such as attention deficit hyperactivity disorder and borderline personality disorder.

 

It is important to note that the ICD-10 is currently being updated and DSM-5 may have an influence on the mental health section of the ICD-11.

Pharmaceutical influence on mental health diagnoses

Healthcare in the US is big business. A 2011 report estimated that the total US spending on health during that year was $2.7 trillion. This represents 17.9% of the country gross domestic product (GDP). In contrast, NHS spending represents just 8.2% of the UK’s GDP. 

However, treating mental health conditions (including dementia) is the highest area of spending within the NHS.

Links and potential conflict of interests between the pharmaceutical industry and the DSM-5 taskforce (the group that revised the manual) are a matter of record. A 2011 article in the Psychiatric Times pointed out that 67% of the task force (18 out of 27 members) had direct links to the pharmaceutical industry.

The DSM-5 taskforce has responded vigorously to these criticisms, pointing out that not only is close co-operation between researchers and industry to be expected, it is also “vital to the current and future development of pharmacological treatments for mental disorders”.

 

“Medicalising” mental health

Some proposed diagnoses in DSM-5 were criticised as potentially medicalising patterns of behaviour and mood.

These criticisms came to public attention after an open letter and accompanying petition was published by the Society for Humanistic Psychology.

In their letter, a group of psychiatrists argued that they were “concerned about the lowering of diagnostic thresholds for multiple disorder categories, about the introduction of disorders that may lead to inappropriate medical treatment of vulnerable populations, and about specific proposals that appear to lack empirical grounding”.

This was followed by a number of high-profile articles by Professor Allen Frances, whose arguments carry more weight than most, as he was chair of the taskforce for DSMIV-TR (the previous update in 1994). In an article entitled DSM 5 Is Guide Not Bible – Ignore its Ten Worst Changes he highlighted changes to the manual that he argued were examples of over-medicalisation of mental health. These changes included:

Asperger’s syndrome

The diagnosis of Asperger’s syndrome has been removed from the DSM-5 and is now part of one umbrella term "Autism spectrum disorder". This is hugely controversial as, according to the ICD-10, those suffering from Asperger’s syndrome have “no general delay or retardation in language or in cognitive development”.

This decision was widely reported in the UK media in 2012.

Disruptive mood dysregulation disorder

Disruptive mood dysregulation disorder (DMDD) is defined by DSM-5 as severe and recurrent temper outbursts (three or more times a week) that are grossly out of proportion in intensity or duration in children up to the age of 18.

This definition is said to be based on a single piece of research, so it is not clear how it might apply to people seeking medical or psychological help for mental health problems in the “real world”.

Prof Frances points out that this diagnosis may “exacerbate, not relieve, the already excessive and inappropriate use of medication in young children”.


Mild cognitive disorder

Mild cognitive disorder (MCD) is defined as “a level of cognitive decline that requires compensatory strategies … to help maintain independence and perform activities of daily living.”

The DSM-5 makes it clear that this decline goes beyond that usually associated with ageing. Despite this, the concept of mild cognitive disorder has been attacked. The main criticism is that there is little in the way of effective treatment for MCD, but if people are diagnosed with the condition it may cause needless stress and anxiety. People diagnosed with MCD may worry that they will go on to develop dementia, when this may not be the case, critics argue.


Generalised anxiety disorder

The "diagnostic threshold" for generalised anxiety disorder (GAD) was lowered in the new version of the manual.

In previous versions, GAD was defined as having any three of six symptoms (such as restlessness, a sense of dread, and feeling constantly on edge) for at least three months. In DSM-5, this has been revised to having just one to four symptoms for at least one month.

Critics suggest that this lowering of the threshold could lead to people with "everyday worries" as being misdiagnosed and needlessly treated.


Major depressive disorder

The most scathing criticism of DSM-5 has been reserved for changes to what constitutes major depressive disorder (MDD).

As you would expect, previous definitions described MDD as a persistent low mood, loss of enjoyment and pleasure, and a disruption to everyday activity. However, these definitions also specifically excluded a diagnosis of MDD if the person was recently bereaved. This exception has been removed in DSM-5.

A wide range of individuals and organisations have argued that the DSM-5 is in danger of "medicalising grief". The argument expressed is that grief is a normal, if upsetting, human process that should not require treatment with drugs such as antidepressants. 

 

How has the DSM-5 been received in the UK?

The reception to the new DSM-5 has been mixed. The British Psychological Society (BPS) published a largely critical response in which it attacked the whole concept of the DSM. It stated that a “top-down” approach to mental health, where patients are made to "fit" a diagnosis is not useful for the people who matter most – the patients.

The BPS said: “We believe that any classification system should begin from the bottom up – starting with specific experiences, problems, symptoms or complaints.

“Since – for example – two people with a diagnosis of ‘schizophrenia’ or ‘personality disorder’ may possess no two symptoms in common, it is difficult to see what communicative benefit is served by using these diagnoses. We believe that a description of a person’s real problems would suffice.”

The UK mental health charity Mind took a more positive approach. The charity’s chief executive, Paul Farmer, said: “Mind knows that for many people affected by a mental health problem, receiving a diagnosis enabled by diagnostic documents like the DSM-5 can be extremely helpful. A diagnosis can provide people with appropriate treatments, and it could give the person access to other support and services, including benefits.”

  

In defence of the DSM-5

Given the criticism listed above you could be forgiven for thinking that the DSM in general and the DSM-5 in particular has no supporters in the world of mental health. This is not the case. Many mental health professionals are proud to defend the DSM-5 and its principles.

Some may cite the fact that given our uncertain knowledge of mental health, having a diagnostic guide is invaluable for doctors to refer to. While the DSM (and the related ICD system) may be a flawed classification system – subject to biases and lacking empirical proof – it is likely to be better than anything else currently available.

Other attempts to classify mental health conditions, have included:

  • systems based on brain biology – such as assessing unusual levels of neurotransmitters
  • systems based on measuring the psychological dimensions of personality (such as extraversion, agreeableness, conscientiousness, neuroticism, openness)
  • systems based on the development of the mind

While these systems are often elegantly expressed in textbooks, none has succeeded in being robust enough to withstand real-world conditions.

As Prof Frances puts it in an essay on the topic called Psychiatric Diagnosis: “Our classification of mental disorders is no more than a collection of fallible and limited constructs that seek but never find an elusive truth. Nevertheless, this is our best current way of defining and communicating about mental disorders.

“Despite all its epistemological, scientific and even clinical failings, the DSM incorporates a great deal of practical knowledge in a convenient and useful format. It does its job reasonably well when it is applied properly and when its limitations are understood. One must strike a proper balance.”

Many people may have sympathy with the British Psychological Society’s response – which could be briefly summarised as “treat the person not the disease”.

But what happens when it comes to research? If you were running a large randomised controlled trial on hundreds of people with schizophrenia you would need some sort of pre-determined criteria of what constitutes schizophrenia. It would be unfeasible to carry out a full psychological assessment of every individual in that trial.

It is also easy to forget how open to doubt psychiatric diagnoses were in the past. In a landmark 1973 paper by David Rosenhan (On Being Sane in Insane Places), eight people with no history of mental illness feigned symptoms in order to gain admission to mental health facilities. As soon as they did gain entry they then stopped feigning any symptoms, yet none of the staff noticed any change in their behaviour. Embarrassingly enough, many other patients did suspect that these people were "not crazy".

Another study from 1971 found that psychiatrists were unable to come to a shared diagnostic conclusion when studying the same patients on videotape.

Therefore any improvement in the diagnostic framework for mental health, however imprecise it may be, should never be taken for granted.

  

Conclusion

Our knowledge about the human mind is dwarfed by our understanding of the rest of the body. We have tools that can confirm a diagnosis of a sprained ankle or a damaged lung with pinpoint accuracy. No such tools currently exist to accurately diagnose a "damaged" mind.

It could be that our current models of human psychology could be as flawed as the "four humours" model of medieval medicine.

Criticisms of the DSM-5, such as the issue of medicalising mental wellbeing, are legitimate areas of debate. This debate is to be welcomed if doctors are to appreciate the scale of the challenges of better diagnosing, treating and caring for people with mental health conditions.

These challenges are likely to persist in the decades to come.

Rather than seeing the DSM-5 as the “Psychiatric Bible”, it may be better to think of it as a rudimentary travel guide to a land we have barely begun to explore.

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Further reading

American Psychiatric Association. DSM-5 Frequently Asked Questions. 2012

American Psychiatric Association. Highlights of Changes from DSM-IV-TR to DSM-5 (PDF, 403kb). 2012

iPetitions.com. Open Letter to the DSM-5. 2012

Frances AJ. DSM 5 Is Guide Not Bible – Ignore its Ten Worst Changes. Psychology Today. Published online December 2 2012

Frances AJ. Last Plea to DSM 5: Save Grief From the Drug Companies. Psychology Today. Published online January 3 2013

British Psychological Society. Response to the American Psychiatric Association DSM-5 Development (PDF, 125kb). June 2011

Frances AJ, Widiger T. Psychiatric Diagnosis: Lessons from the DSM-IV Past and Cautions for the DSM-5 Future (PDF, 288kb). Annual Review of Clinical Psychology. October 2011

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Comments

The 9 comments posted are personal views. Any information they give has not been checked and may not be accurate.

kevaine said on 17 March 2014

Continued (final post)...

Yes, there may be mental illnesses with organic causes… but we do not yet possess the technology to fully look inside and fully understand the brain. So, diagnosis of such “diseases” remains speculative. A person presenting as “Bi-Polar” could just as easily be hiding a long back history of childhood abuse and neglect – and might, were this to be uncovered, benefit far more from “talking therapies” than from pills. They might also, therefore, benefit hugely from avoidance of being incorrectly labelled “Bi-Polar!

Only holistic care can truly reflect the human. Labels are not holistic, they are reductive in nature. If we are truly to provide care that has the best interests of patients at heart (as opposed to being influenced by budget, politics or “the system”) then we need first and foremost always to see the human… and not the label.

READING:
journals.psychiatryonline.org/article.aspx?articleid=85481
http://www.nimh.nih.gov/about/director/2011/improving-diagnosis-through-precision-medicine.shtml

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kevaine said on 17 March 2014

Continued...

A “diagnosis” (i.e. label) may then be produced on the basis of medication that the patient responds to. How accurate is this? Recent research certainly shows a lack of evidence to validate the practice! It could also be argued that labels do not fully reflect the extent of patients’ experiences, nor do they encapsulate all that lead to the point at which the patient now finds him/herself. Many people who are abused in early life struggle to express what has happened to them; many never do. Instead, they may present as “mentally ill”, “disturbed” or similar. But are they? Do they really need medication? Do they really need a label? We really ought to stop and think about this one! The truth is that were any of us to be placed in a position where we were bullied or abused as youngsters; let down by those who ought to have provided nurturing, care and support; we would all react negatively. This would be perfectly natural. Each and every one of us is equipped with emotions, which help us to react to various situations. Emotions are a Natural part of being.Put bluntly… each and every one of us who has known bereavement, has also known grief, loss, melancholy, hurt, anger, denial, frustration… each and every one of us who has experienced relationship breakup may have also known pain, loss, remorse, hurt, self-doubt… there is nothing “abnormal”, or “mental”, about this. So, there is nothing “abnormal”, or “mental” about the abused or traumatized (young) person who experiences rage, hurt, pain, upset, anger, fear, withdrawal, denial, mistrust, confusion…did we all somehow leave freud and jung(amongst others)in the “basement”? Where is our understanding of “defensive mechanisms”? To act in a defensive manner with regard to past trauma does not automatically imply pathology. We need to find a better, more appropriate, more sensitive way of looking at things.

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kevaine said on 16 March 2014

Continued...

For a long time, there has been a lack of parity between health care for physically ill people, and health care for mentally ill people, with those who are mentally ill being viewed in some way as “pariahs”. Though the days of “Asylums” and other such horrors are allegedly long gone, societally we still hold onto a view of mentally ill people that is stigmatizing and degrading. We assume lack of competence, lack of capability. We assume that they are “different” or “weird” – labels only add to this. We need to encourage a system that sees beyond such things, in more ways than one. We need to ensure that patients who need treatment and support are not forced to access it in ways that leave them open to stigma, and negative associations. We need to ensure that patients are seen first and foremost as humans.

For example… is Stephen Fry merely Bi-Polar, or something far beyond that? Bi-Polar does not in any way define his intellect, talent, creative ability, wit, determination… We must be aware that labels often stick, and that once there – even if they prove to be inaccurate – they are hard to eradicate. Labels, even wrong labels, leave a legacy. They diminish people; in the case of those who are mentally ill, labels erase from view any good qualities the person may have, and supplant instead a whole host of negative stereotypes.

Besides, to argue that labels are necessary in order to allow for the administration of medication is a fallacy. Much of the labelling that goes on in mental health care is as a result of trial and error treatment (see links to papers on this subject). Put simply, the patient who presents with “X” symptoms is put initially on “Y” medication to see if it works. If it does not relieve symptoms after a specific period of time, the patient then gets to try “Z” medication – and so forth until a medication is found that “suits” the symptoms.

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kevaine said on 16 March 2014

This is a difficult one; I live in the UK, where we do not have to rely upon insurance to meet medical costs. We, do, however utilise both the DSM and the ICD as diagnostic tools in the field of mental illness. What worries me is that there is so much overlap of symptoms in these manuals from one illness to another, that it could be argued they may make diagnosis more confusing. What one practitioner may see as “Reactive Depression” another may interpret as “Post Traumatic Stress” – simply because of the overlapping of symptoms. The point, then, becomes what is the correct diagnosis? Especially as diagnosis can affect treatment options, even here in the UK.

To justify use of labels in the UK simply because this simplifies matters for insurance companies in a foreign country (U.S.) is simply not acceptable. Labels come with all sorts of associations attached, many of which (when referring to mental illness) can be significantly negative in nature. Use of labels implies a use of “shorthand” in which the patient often “becomes” the label. We all know the negative connotations associated with labels such as “schizophrenic”, “personality disorder” – labels that are easily adopted by the media, who wish to sell sensationalist stories that do not always reflect the true nature of mental illness, and patient experiences. Human beings – even those who are mentally ill – are complex creatures, far more than just labels. When we stoop to using labels as rote; rather than questioning why we are doing so, and what said labels actually mean; we do a disservice to humanity.

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musbcrazy80 said on 21 January 2014

I challenge any psychiatrist to define these so called mental illness's...lets hear your explanation, scientific one of course of what adhd is.

show me one test, x-ray or study finding that scientifically proves the existence of a chemically imbalanced child and not a typical normal child whose perhaps more excitable, active or more curious than their peers.

the push to drug our children in exchange for corporate profit will be recognised and justifiably punished.

DSM edit 1 1952- 130 ages ong and 102 conditions
DSM edit 2 1968 -132 pages 182 conditions
DSM edit 3 1980 -494 pages 265 conditions
DSM edit 4 1994 -886 paes 297 conditions
(seeing a pattern yet?)
DSM edit 5 2013 (this version is extra special as its iinsrance company fiendly hepfully matching up claim codes and illesses to make funding quicker. Coz thats what counts!!!

And as an extra bonus theyve even thrown in a new type of illness,one thats not there yet but can be predicted to be present in the future.

Bit like a fortune teller, but probaby less accurate...Shocking profession and complicity of the NHS

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runwellian said on 03 January 2014

The problem with the ICD 10 is that patients are not diagnosed using a multiple choice quiz that most certainly doesn't fit the most of cases.
It gives patients unfair unwarranted labels and the only guarantee is that they will get a prescription for drugs, but very little real help.
With an ICD10 and an BNF, anyone can be a psychiatrist, you only need to be able to read and tick boxes.

It is time doctors started to look at causes and not just treat symptoms, mental health care needs a revolution, but for the cruel treatments being stopped, mental health care is not much better now than it was back in the 50's.

In those days staff had quality time to spend with patients, giving the patient time to open and and talk about their problems, today staff are too busy ticking boxes!

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barry stanley said on 13 December 2013

Once more the AMA fails to acknowledge FAS / ARND [ FASD ]

Unfortunately the new diagnosis [ four grades ] of Intellectual Disability is going to be used for all those children who do not meet the requirements for autism and adhd etc and are actually FASD. Pediatricians and child psychiatrists will have no need to pursue the question of PAE, something I saw on a daily basis in practice.
Where the evidence of PAE cannot be ignored the new diagnosis of ND – PAE [ code 315.8 ] will be used creating even more confusion for those with FASD and the families that support them.

Barry Stanley

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Ronald Pies MD said on 13 September 2013

The criticism of DSM-5's decision to eliminate the so-called "bereavement exclusion", when diagnosing major depressive disorder, has been largely unjustified. The decision does not "medicalize" ordinary grief; rather, it allows the diagnosis of major depression to apply when a bereaved person meets all symptom, duration, and severity criteria for major depression. The death of a loved one (bereavement) does not "immunize" the patient against major depression; on the contrary, bereavement is a common precipitant of this potentially life-threatening disorder. For more on this, please see my article at:

http://psychcentral.com/blog/archives/2013/05/31/how-the-dsm-5-got-grief-bereavement-right/

Ronald Pies

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runwellian said on 03 September 2013

The problems with labelling folk is that doctors stop seeing a real person or their problems and just look fro an appropriate label.

One cover doesn't fit all and we need to move away from that.
Mental health care is more about medications that root causes. I am am depressed being prone to depression, and another person is depressed because they have lost their job and may lose their home, so how come the same medication is given? Doctors need to look at root causes, then we wouldn't need medication that doesn't really work, for the rest of our lives.

We don't need labels, we need real help!

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Edited by NHS Choices

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