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May 22, 2013

Revision of Mental Illness Guide Stirs Debate

by Jessica Berman

A long-anticipated revision of an official diagnostic guide to mental illness, known as the DSM-5, was released this week.  While the new manual is being welcomed by some doctors as reflecting advancements in the understanding and diagnosis of mental disorders, critics say its definitions of psychiatric conditions are based too much on symptoms and too little on the biological causes of mental illness.

The DSM, or Diagnostic and Statistical Manual of Mental Disorders, is considered by many psychiatrists and psychologists to be the “bible” by which they can diagnose and treat their patients' mental illnesses.
 
It’s been nearly 20 years since the DSM's publisher, the American Psychiatric Association, or APA, did a major revision of the voluminous guide.

David Kupfer, a professor of psychiatry at the University of Pittsburgh in Pennsylvania, headed the international task force that put together this fifth version of the DSM.  Kupfer says it was time to update the manual, a process that took the task force a decade to complete.

“We are quite excited about putting out DSM-5 as a revision due to the fact that many things have happened over the last 19 years; that it was felt, in terms of scientific evidence that we were ready for a change,” Kupfer said.

For example, the manual drops the separate diagnosis of Asperger’s syndrome, a developmental disorder marked by significant difficulties with social interaction, and folds it into a broader category called autism spectrum disorders.
 
Asperger’s is considered the mildest form of autism, which can cause an inability to communicate with others, emotional outbursts and repetitive behaviors.

Kupfer believes that the change in the Asperger’s designation is relatively minor. But Alycia Halladay, a senior director of Autism Speaks, an advocacy group for people with autism, thinks otherwise.  Halladay says people who were previously diagnosed with Asperger’s will still have access to special treatment and training programs in the U.S.

“We’re concerned about individuals who may have shown symptoms of Asperger’s or may show symptoms of what was called Asperger’s not meeting the criteria for what is now called autism. And therefore not receiving services,” Halladay said.

Another significant change in DSM-5 that critics have targeted is its revised definition of depression.  The old criteria were that a patient had to display symptoms of unhappiness or lack of pleasure for weeks or months at a time.  

Now, the manual specifies that a psychiatrist may diagnose a patient with clinical depression after just two weeks of persistent sadness.

“[To] Diagnose major depression after a bereavement is medicalizing a normal human reaction, that is the grief of losing a loved one,” explained Bruce Cuthbert, coordinator of the US National Institute of Mental Health’s Research Domain Criteria Project or RDoC.  RDoC is tasked with pulling together the latest research identifying the biological underpinnings of mental disorders such as depression and schizophrenia.

Cuthbert says the DSM-5 continues the prevailing symptoms-based approach to the diagnosis and treatment of patients with psychiatric disorders.  It's an approach he calls “hit or miss” since the drugs and therapies prescribed to relieve a mental health condition don't always work as hoped.  As a result, Cuthbert says, doctors frequently resort to trying different medications on the same patient.  

Cuthbert says mental health research also tends to follow definitions outlined in the DSM manual.

“That’s what we need to change, because we know that these categories are very complicated.  There are many different mechanisms of brain functioning and behavior that are involved with any one of these disorders,” Cuthbert said.

As scientific research sheds new light on the biological causes of mental illness, Cuthbert says doctors will be able to target increasingly effective treatments for their patients' psychiatric disorders.  Experts say those advances will be incorporated by the American Psychiatric Association in future revisions to its DSM.