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Latest Edition of Psychiatry's 'Bible' Launched Amid Controversy

Authors say it defines disorders more concisely; critics say it will lead to over-diagnosis and unnecessary treatments
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WebMD News from HealthDay

By Dennis Thompson

HealthDay Reporter

MONDAY, May 20 (HealthDay News) -- As the American Psychiatric Association unveiled last week the latest edition of what is considered the "bible" of modern psychiatry, 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 characterizes and categorizes disorders.

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.

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.

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