The DSM 5

The DSM 5

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is almost like a bible to the likes of clinicians, researchers, insurance companies and many more. Ever since the very first edition back in 1952, there have been many debates and controversies surrounding the book. When the first edition came out, it contained 106 mental disorders in its pages which almost doubled by the time the 4th edition came by in 1994 with 297 disorders. Here we are at the end of 2013, roughly about 6 months passed since the latest release of the DSM 5. There have been talks about the new DSM 5 for quite some time now and there seem to be a lot of people disagreeing with the changes they have made. This article will talk about a few of the many controversies around the DSM. The unreliable diagnosis that clinicians are giving to people, knowing that patients will get different diagnosis from one psychiatrist to the next does not inspire confidence or sound promising. Even though all the clinicians are all using the same book and following the same guidelines listed within its pages, there just isn’t enough time in the real world situation for every patient. It will talk about many of the changes and additions to its previous version. Controversies surround sexuality and gender issues in DSM and also talk about many of the new disorders included in the new version. For example, disorders such as disruptive mood dysregulation and binge eating disorder and the usefulness of their existence. With the many additions, there are a lot of things that can go wrong, false diagnosis is a very strong possibility and also the danger of over dosing people with all these drugs for all of these disorders. It is a great time however for many drug companies. Transparency is the key and perhaps money was a big motivation for the change, new disorders mean more pharmaceutical sales.

The first concern with the DSM is something that’s been a problem in the past and this new version of the DSM doesn’t seem like it will resolve the issue. The problem is the reliability, consistency and validity of the manual. Even back in the older versions of the DSM efforts were made to increase its reliability. The thought was that in a perfect world, psychiatrists could use the DSM effectively by going through all the details and spending a lot of time with the patient to come up with a reliable diagnose. But in the real world, that kind of time and attention just isn’t possible for every patient that walks through the door. “If a researcher or a clinician can afford to spend 2 to 3 hours per patient using the DSM criteria and a structured interview or a rating scale, the reliability would improve” (Maria, 2012). The difficulty of the problem comes from the lack of time clinicians have and there isn’t any easy solution or quick fix to solve this problem. “There’s still a real problem, and it’s not clear how to solve the problem” (Maria, 2012).

To further demonstrate this problem a study was done by 2 authors named Herb Kutchins and Stuart A. Kirk. The 2 coauthors undertook a reliability study that was conducted at 7 different sites, 1 in Germany and 6 others spread out in the United States. During the study, they took experienced mental health professionals and provided them with extensive training on how to properly use the DSM to make accurate diagnoses. Right after the training, the professionals were paired up and put into a room to interview roughly 600 potential patients. However the results showed that there was no improvement in reliability. This is a scary fact because it suggests that in the real world, clinicians without the special training and the more important factor, time constraint, would do considerable worse. Especially since in the study, the standards for defining the agreement of a diagnosis was set pretty low. “For example, if one of the two therapists made a diagnosis of Schizoid Personality Disorder and the other therapist selected Avoidant Personality Disorder, the therapists were judged to be in complete agreement of the diagnosis because they both found a personality disorder – even though they disagreed completely on which one” (Levine, 2012). Even professionals with special training would often disagree, that’s not very reassuring for anyone to believe the proclaimed increase in reliability. Furthermore, Kutchins and Kirk noted that there was not a single major study out there that would support a strong level of reliability in any versions of the DSM. Therefore our expectations of diagnosis from DSM 5 should be set to what is known, low level of validity and reliability rather than unrealistically high standards. Obilos said “To see a kappa value for a DSM 5 diagnosis above .80 would be almost miraculous; to see k between .60 and .80 would be cause for celebration” (Obilos, 2012). This would suggest that while we aim for .60 and .80 anything from .40 to .60 would probably be the norm, in some cases maybe even lower.

With such low reliability, the DSM makes it even harder to have an accurate diagnosis especially with its revisions and all its newly added mental disorders. Let’s first take a look at one of the biggest revision controversies around the DSM, sexuality and gender issues, more specifically, Gender Identity Disorder (GID). This isn’t the first time a gender issue has come up in the DSM. The APA listed homosexuality in the DSM as a disorder from the first version of the book. It wasn’t until 1974, in the 7th printing of the DSM-II that it was taken out with protests by the gay rights activists. In the case of GID, there were many people on both sides of the argument. On one hand, people advocated for the DSM to remove GID, to indicate that it is normal to have a non-binary gender identity in today’s society. On the other hand, other people wanted to keep the GID because they worry about getting insurance coverage for the gender reassignment surgeries. It is hard enough to get coverage now, that they fear it would be even more difficult if it was no longer diagnosed as a disorder by mental healthcare professionals. Ultimately, they decided to change the name from gender identity disorder to gender dysphoria. “GD – a diagnosis that recognizes the emotional stress associated with having a gender identity that is incongruent with one’s physical body but does not conceptualize cross gender identification as a disorder in and of itself” (Boskey, 2013). This perhaps is a positive change that gave balance to the wants of both sides.

Now let’s take a look at some of these newly added disorders, which are very questionable in terms of the need for them and also their importance. For instance, let’s look at grief. In the version prior to the 5th, the DSM had something called “bereavement exclusion” in it. It basically states that when you lose someone you love, it is very normal and human to grief for them. Even if the grief is accompanied by signs of depression, it should not be considered a mental disorder of depression. However, this is no longer the case as Bruce states “Come this spring, normal human grief accompanied by depression symptoms will be a mental disorder” (Levine, 2013). Another example is the newly added “disruptive mood dysregulation disorder” (DMDD). This means children who have temper tantrums are now considered to have mental disorders. Now parents will be worrying about a mental disorder the next time their kid refuses to eat their vegetables and throws a hussy fit. Another new disorder they added is the “binge eating disorder”, which was previously in the DSM 4 but in the non-official mental illness section in the appendix. So what exactly does this disorder mean, well according to Frances taken out of Levine’s article, “Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness called binge eating disorder” (Levine, 2013). This is a really unclear and useless addition. For example, say you are a student who lives on campus and travels home on the weekends. Now in a 3 month period, that is easily more than 12 meals at home. What if you really miss your parent’s cooking or just sick of eating out while at school. This doesn’t and shouldn’t classify you an individual with an eating disorder. Perhaps one of the most useless additions in DSM 5 is the “minor neurocognitive disorder”. It pretty much deals with bad memory which is a characteristic of getting old in itself. It is very normal and expected for someone to lose some of their memory as they start to get older and older. This disorder is suppose to be an early sign of dementia but with there being no effective treatment for dementia, there isn’t much use for this diagnosis at all. On top of everything it adds stress to people who are diagnosed, which could actually be counter active. For example, suppose you have a hypothetical patient who will eventually get dementia, up on receiving this new diagnose, it might add stress in their life and create a great deal of anxiety that could possible lead to an early onset of dementia. With all these newly added disorders, they pose some serious problems.

The first problem that comes to mind is the possibility of false positives. There is already low reliability on the DSM but with some of these new disorders, it is very easy to misdiagnose because it really can go both ways. For example, let’s take the previously mentioned binge eating disorder. It is very hard to tell the difference just based on a person eating a lot 12 times out of a 3 month period, assume 3 meals a day that is 279 meals give or take. How can you say that someone have an eating disorder by simply eating excessively for 12 out of 279 meals? That’s only about 4.3% of the meals they eat. Is it so hard to believe that 4.3% of the time people might run into food that they really love and enjoy so they decide to have a little more than usual? Allen Frances, former chair of DSM 4 taskforce stated that DSM 5 is going to introduction us to a new concept, “behavioral addictions”. It means that eventually they will create a disorder for everything that we do a lot of. There are a lot of opportunities for false positives and further more an even more dangerous problem is the use of medication for people everywhere. This is especially true in young children in the case of disruptive mood dysregulation disorder. It was created to reduce the large raise in the number of children diagnosed with pediatric bipolar disorder. However with a less diagnosis means lesser requirements for disorder and that means more children will be diagnosed with DMDD which will increase the already excessive use of medication in children. “DSM 5 should not be adding a new disorder likely to result in a new fad and even more inappropriate medication use in vulnerable children” (Levine, 2012). He also mentioned that false positive rates are as high as 70%-75% in careful studies and probably higher in the real world. Obiols mentioned that there will be tens of millions of newly misdiagnosed false positive patients which will only make the existing problem of overly inclusive DSM IV worse.

Furthermore, there are hundreds of thousands of young adults taking atypical antipsychotic drugs in hopes of preventing psychotic episodes which doesn’t even seem to work. “There is no proof that the atypical antipsychotics prevent psychotic episodes, but they do most certainly cause large and rapid weight gains and are associated with reduced life expectancy to say nothing about their high cost, other side effects and stigma” (Obiols, 2012). Eventually, children or adults, the increase number of disorders and diagnosis will surely increase the use of medication in our society. So what is pushing the increase need of medication? There seem to be a lot of talk about this issue saying how it is all just a way for drug companies to profit. Allen Frances believes that the high rate of false positives will become a target for drug companies. Also with the controversial changes to obesity, internet addiction, anxious depression and such, Lane worries that the credibility of the DSM is in question. “Some critics argue that the addition of new disorders to the manual is little more than a pretext for prescribing profitable drugs” (Kaplan, 2009). The APA isn’t helping their case by mandating the DSM task force members to sign a nondisclosure agreement. It was eventually lifted when Robert Spitzer and Allen Frances criticized them publicly. It was also mentioned in Obiol’s article that it has been reported 70% of the DSM 5 task force member have direct industries ties. The key for the DSM’s successes going forward is going to be transparency. The more they hide from the public the more likely we will question them about all these controversies.

In conclusion, the only good news about the new DSM that was released in May of this year might be the hefty price tag of $199 per copy; at least no one is rushing out in a hurry to purchase one to blindly follow. The APA’s decision to make their task force members to sign a nondisclosure from the start really ruins its attempt to be transparent. The new version of the manual fails to revamp one of the most important issues, reliability. Even in research environment with professionals given special training, there still was a lack of reliability on the diagnosis. This problem is further compounded by the inclusion of many questionable disorders such as binge eating disorder, minor neurocognitive disorder and disruptive mood dysregulation disorder. All these new inclusions increased the change of false positives and greatly amplified the danger of the inappropriate and overuse of medication in both adults and young children. This just seems like a great opportunity and target for drug companies to make a killing. Perhaps one of the only good things the new DSM has to offer is the change of gender identity disorder, they managed to balance the needs of each side by replacing it with the Gender Dysphasia.
References
BOSKEY, E. (2013). Sexuality in the DSM 5. (cover story). Contemporary Sexuality, 47(7), 1-5.
Himmelhoch, J., Mezzich, J., & Ganguli, M. (1991). Controversies in psychiatry: The usefulness of DSM-III. Psychiatric Annals, 21(10), 621-631.
Kaplan, A. (2009). DSM-V controversies. Psychiatric Times, 26(1), 1-10.
Levine, B. (2013, February). Rejuvenating Abolitionism of Psychiatric Labels – Even Some Establishment Psychiatrists Embarrassed by New DSM-5. Mad in America.
Maria, C. (2012, September). Psychiatry And Modern Science: Perspectives On The DSM. Huffington Post.
Obiols, J. E. (2012). DSM 5: Precedents, present and prospects. International Journal of Clinical and Health Psychology, 12(2), 281-290.

References: BOSKEY, E. (2013). Sexuality in the DSM 5. (cover story). Contemporary Sexuality, 47(7), 1-5. Himmelhoch, J., Mezzich, J., & Ganguli, M. (1991). Controversies in psychiatry: The usefulness of DSM-III. Psychiatric Annals, 21(10), 621-631. Kaplan, A. (2009). DSM-V controversies. Psychiatric Times, 26(1), 1-10. Levine, B. (2013, February). Rejuvenating Abolitionism of Psychiatric Labels – Even Some Establishment Psychiatrists Embarrassed by New DSM-5. Mad in America. Maria, C. (2012, September). Psychiatry And Modern Science: Perspectives On The DSM. Huffington Post. Obiols, J. E. (2012). DSM 5: Precedents, present and prospects. International Journal of Clinical and Health Psychology, 12(2), 281-290.