The new DSM-5 draft is out (and it appears the APA is finally dropping the silly roman numeral designations). Analysis is starting to pour in from around the country about the ramifications of the new diagnoses and proposed changes.
To start with, however, I want to congratulate the American Psychiatric Association for reaching this milestone and embracing the ability for the public to comment on the proposed changes. We first called for such an option back in December of last year and it appears somebody at the APA was listening. Kudos for being willing to take the barrage of criticism that is coming your way, APA. However, we wish it was an open commentary model, where the comments appears online for all to read (it appears to be a closed model, where your comments disappear into cyberspace with the hope that someone is actually reading them).
Some may criticize the draft for reasons relating to how “popular” a proposed diagnosis may become. I find such logic shaky at best. You can’t suggest diagnoses not be included on the reasoning that too many people may be diagnosed with them if they make it into the final revision of the DSM-5. Also, I’m not a big fan of folks who try to predict the future. We’re supposed to be professionals here, not fortune tellers.
The Good in the DSM-5 Draft
Before I review some of the concerns I have with the DSM-5 draft, let me also note some of what I view as beneficial changes.
1. Inclusion of Binge Eating Disorder
While some may decry the inclusion of this disorder in the draft, I can’t see how it can be any other way. This diagnosis has been in the current DSM for 16 years (in the section of disorders needing further study), and has undergone a lot of research during that time. On behalf of millions of Americans who have long suffered from this problem but couldn’t be diagnosed with it, I think folks will be thankful this is finally being recognized as a legitimate disorder.
2. Suicide Risk Assessment
It’s nice to see the manual embrace a slightly more formal process for assessing suicidal risk. Suicide remains a tremendously difficult problem to address, so I find anything that helps a clinician review their client’s risk a potential positive.
3. Combining of the Two Categories: Substance Abuse with Dependence
To me, this has always been a confusing distinction without a difference, that seemed to make little difference in the proposed treatments. The proposed change — which combines the abuse category with the dependence category — brings these kinds of disorders in alignment with how other mental disorders are diagnosed. For example, we don’t differentiate between someone who has brief, episodic manic episodes and someone who has longer-term manic episodes. It’s enough to note the differences in the specifiers that accompany the new proposed disorders (e.g., Substance Use Disorder or Alcohol Use Disorder). Seems like a long-needed change.
4. Aligning Autism Disorders
While some people may disagree with the proposed change of bringing in Asperger’s disorder within a newly named Autism Spectrum Disorders (to encompass all autistic behavior disorders), I see this as a positive change. Nobody who has a disorder likes it when these kinds of name changes occur to their diagnosis. But it helps clarify and properly categorize the disorder, which is what the diagnostic manual is all about.
5. Inclusion of Self-Injury
We’ve seen a significant rise in the number of people who use self-injury as a means of coping with their lives, that it turns into a behavior that can become difficult to control. There’s no good diagnosis for a person today who has self-injury behavior, but few other symptoms. The inclusion of self-injury as its own disorder is likely to help people who currently do this to seek out help.
The Bad in the DSM-5 Draft
1. Behavioral Addictions
As long-time readers know, I’m no fan of the term “behavioral addictions.” I believe such a term leads us all on a slippery slope that knows no bounds which could end up classifying virtually any human behavior that can be overdone. Watching TV, reading books, heck even talking to your friends and socializing could all become “behavioral addictions.” Clearly, this new category was meant to someday include addictions like “sex addiction” and “Internet addiction,” but for now only includes the existing disorder, Pathological Gambling. This is a bad change and we would recommend the workgroup revisit.
2. New/Updated Sexual Disorders for Legal Reasons
It seems like some of the updates — like one for pedophilia expanding to include teens — and new disorders — like Paraphilic Coercive Disorder — are being proposed more for legal or pragmatic reasons, not based upon clinical research data. While the DSM has always been a slave to the politics and realities of the world it tries to accurately reflect, these changes seem poorly conceived. They would give criminals additional opportunities to claim “mental incompetence” and face a different (and often lighter) sentence because of it.
3. The Medicalization of Grief
Do we really need this? Dr. Ronald Pies predicted this one a year and a half ago and it appears to have come true. Grief is a highly individualized and personal experience and it seems to make little sense to call it a disorder just because it’s severe.
4. Minor Neurocognitive Disorder
On the fence about this one, but am leaning toward seeing this as an attempt to further medicalize normal aging. The proposed criteria do nothing to differentiate this from normal aging, where it is normal for many to have difficulty with or even lose the ability to do things one could normally do even just a few years earlier. Knowing that the recommended formal neurocognitive testing would rarely be carried out in real world settings, this seems like a new disorder ripe for being misused.
The Ugly in the DSM-5 Draft
1. Temper Dysfunctional Disorder with Dysphoria
I could probably just stop at the name and you would see how wrong this is. This is for a tiny slice of childhood (you have to be between ages 6 and 10 to receive this disorder; what happens if, at age 11, you still have the symptoms is a mystery). It is characterized by “temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property.” So, in other words, a temper tantrum. Something children have been doing for centuries is apparently now a serious enough problem to warrant its own disorder? No, I don’t think so.
2. Dimensional Assessments
Dimensional assessments are simply measures that allow a clinician to gauge a wide range of symptoms that “cross cut” across many disorders. While well-intended, they are complex (the description of them alone is longer than this entire article!) and add another level of work to already over-worked clinicians. The benefits of this kind of assessment largely remains unknown, and without a clear benefit, insurance companies are unlikely to require their use. Meaning they will be relegated to the bin of “good ideas badly implemented.”
We’ll have more thoughts on specific changes in the days to come, so stay tuned. Check out the DSM-5 Draft here, where you can also register to submit your own comments.
Want another take? Check out Opening Pandora’s Box: The 19 Worst Suggestions For DSM5 in the Psychiatric Times by Allen Frances, M.D.