As the American Psychiatric Association unveils the latest edition of what is considered the "bible" of modern psychiatry this weekend, the uproar over its many changes continues.
"This is unprecedented, the amount of commentary and debate and criticism," said Dr Jeffrey Lieberman, president-elect of the American Psychiatric Association (APA). "It's been an interesting phenomenon, but the evidence is what it is. You have to evaluate it and then make your own determination of how compelling it is, and what would be best clinical practice."
The APA believes that changes made in this fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) will allow for more precise diagnoses of mental illnesses in patients, because this edition better characterises and categorises disorders.
Diagnosis of mental illness in people
But it has drawn fire from critics who are concerned that the revised version will lead to the diagnosis of mental illness in people who are simply being challenged by life.
More than 1 500 experts from 39 countries representing a wide variety of medical fields contributed to the new DSM-5, which was more than a decade in the making. Drafts of the manual were made available online as part of three open-comment periods that drew more than 13 000 responses.
One of the most notable naysayers has been Dr Allen Frances, chairman of the task force that created the DSM-4, the previous version of the guide that has been in use since 1994.
In a commentary released the day of the DSM-5's release, Frances wrote that this latest revision introduces "several high-prevalence diagnoses at the fuzzy boundary with normality," and predicted that the changes "will probably lead to substantial false-positive rates and unnecessary treatment."
"In DSM-5, normal grief becomes a major depressive disorder, temper tantrums become disruptive mood dysregulation disorder, worrying about medical illness becomes somatic symptom disorder, gluttony becomes binge eating disorder and almost everyone will soon qualify for attention-deficit disorder," Frances said in an interview.
Mental disorders to take note of
The main points of contention regarding the DSM-5 include:
The combination of a number of autism-related disorders into a single category called autism spectrum disorder. Although some clinicians believe that placing autism on a continuum from mild to severe will allow for more accurate diagnoses, others are concerned that high-functioning people with autism will find themselves unable to receive services or treatment. This is particularly true of people with Asperger's Syndrome, a diagnosis that has been eliminated from the DSM-5, critics of the new version contend.
"We're concerned that people who have Asperger's - who have high-functioning autism - are going to be dismissed as just being different when the majority of adults with Asperger's will need people to assist them in parts of their lives," said Karen Rodman, president and founder of Families of Adults Affected With Asperger's Syndrome.
"We are very concerned that medicine is going to drop the ball again, and the children who need services won't get them," Rodman said. "Fortunately, clinicians and physicians and the public around the world are still going to refer to Asperger's as Asperger's. It's like saying people don't have a right arm anymore.
"Many people with Asperger's are [also] concerned there will be a stigma -- that everyone will be considered autistic - and when people think of that they think of a child sitting in a corner and spinning," Rodman added.
- Changes made to the diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD). Critics are concerned that changes made to better diagnose ADHD will instead lead to over-diagnosis. In the previous version of the DSM, a person needed to show the onset of symptoms before age 7 to be diagnosed with ADHD. The new version now says 12 is the latest age at which ADHD symptoms can manifest themselves. The DSM-5 also reduces the number of criteria needed to arrive at a diagnoses of adult ADHD from six to five.
- A new diagnostic category for children who are hostile or acting out. The DSM-5 includes a new category called disruptive mood dysregulation disorder, which would apply to children who have extreme irritability but fall short of the standards for bipolar disorder or depression. The category was created to deal with the upswing in bipolar diagnoses among children, but there is concern that some clinicians will label a simple childhood temper tantrum as a treatable mental illness.
- Breaking out obsessive-compulsive disorders into their own category. Obsessions such as hoarding, hair-pulling and skin-picking had been considered anxiety disorders, but in the DSM-5 they will have their own category. Critics are concerned that this change has more to do with reality television's recent focus on hoarders than with the need for a new category of mental illness.
Lieberman called the DSM-5 "a reflection of the state of our scientific knowledge," and strongly disagreed with the notion that over-diagnosis and overmedication will be the end result of the manual's new standards.
Need for treatment for patients
"This doesn't reflect any expansion of the people who would be diagnosed. It just classifies them in a more concise and accurate way," he said. "The goal of the DSM is not to expand the number [of people] who receive diagnoses who don't warrant them. The reality is that there is tremendous under-treatment of people with real needs, and this new revision will help."
Reflecting on the strong reaction to the changes, Lieberman said it may go hand-in-hand with the public's uneasiness with mental illness.
"I think there's a strong stigma factor associated with mental illness," he said. "There are people who are either fearful of it or want to minimize its existence. That stigma has been historic, but it has been diminishing with greater education and research and better treatment."
For his part, Frances ascribes nothing but good intentions to those who worked on the new DSM, but is concerned that their efforts will lead to bad outcomes.
"The people who are suggesting these changes are experts in their field who are pure of heart, but they have made terrible decisions because they don't understand that new diagnoses that may work well for them can be an absolute disaster in everyday care, especially when drug companies get their hands on them," he said.
Frances has written a new book, Saving Normal, in which he argues that mental illness is over-diagnosed in America. He urged both parents and clinicians to be skeptical when it comes to the DSM-5 and any diagnoses that spring from it.
"My advice to physicians is to use the DSM-5 cautiously, if at all," Frances concluded in his commentary. "It is not an official manual; no one is compelled to use it unless they work in an institutional setting that requires it."
Fore more on the DSM-5, go to the American Psychiatric Association.