DSM-5: a ‘living document’ that may impact practice, patients health

 

  • December 21, 2012

There are a number of changes to the diagnostic criteria in the upcoming DSM-5, many of which may affect clinical practice, according to experts.

There were more than 12,000 emails and letters and nearly 13,000 comments during the three public-comment periods of the development of the DSM-5, according to the American Psychiatric Association. Thirteen workgroups were in charge of drafting proposed changes to the manual, paralleled by three separate reviews by the DSM-5 Task Force, a Scientific Review Committee, and a Clinical and Public Health Committee.

“We have sought to be conservative in our approach to revising DSM-5,” David J. Kupfer, MD, chair of the DSM-5 Task Force, said in a statement. “Our work has been aimed at more accurately defining mental disorders that have a real impact on people’s lives, not expanding the scope of psychiatry.”

The APA said the Arabic numeral used to identify the new manual indicates a living document, open to change as new research emerges. Incremental updates to the manual will be identified with decimals, changing to 5.1, 5.2, and so on.

However, some experts said the changes recently approved by the APA may be harmful to patients seeking mental health care. Allen J. Frances, MD, professor emeritus of psychiatry and behavioral sciences at Duke University and chair of the DSM-IV Task Force, said clinicians will need to be careful when diagnosing patients based on the new criteria.

“Be cautious,” Frances told Psychiatric Annals. “The changes are not based on a careful risk–benefit analysis, and they’re likely to lead to massive over-diagnosis and excessive treatment, particularly with medications.”

Frances said drug companies may seize on some of the new changes featured in the DSM-5, such as the removal of the bereavement exclusion criterion.

“Take the [shooting] incident in Connecticut,” Frances said. “… If [those who are grieving] have symptoms of sadness, loss of interest, reduced energy, trouble sleeping, and problems of appetite, DSM-5 will allow this perfectly normal reaction to tragedy to be misdiagnosed as major depressive disorder, and drug company salesmen can say that depression is being missed and these people can be helped with medication.”

To safeguard against over-diagnosing and over-medicating patients, Frances proposed that there should perhaps be a governing body to oversee the effect of the changes, similar to how the FDA administers postmarketing surveillance of drugs.

“There should be a very intense study of the impact of the new changes,” Frances said. “And if rates [of mental illness] suddenly jump, that should be a cause for concern.”

Psychiatric Annals Medical Editor Jan Fawcett, MD, who chaired the DSM-5 Mood Disorders Work Group, said he and colleagues had decided to remove the bereavement exclusion to allow clinicians to determine for themselves the correct diagnosis and appropriate course of treatment.

“So the question is, does the patient have a major depression or not, and what treatment does it require? We think clinicians can make that decision for themselves without all kinds of specific rules that were in the bereavement exclusion,” Fawcett said.

He told Psychiatric Annals that those in charge of drafting changes to the manual did so based on available evidence.

“We’ve been working on this for 5 years... The DSM-5 is pretty much what was proposed by the workgroups for the most part,” he said. “You never get every detail or every issue addressed, but I think what we did was useful and will be helpful and will carry us forward.”

Revisions in the DSM-5 also include the following:

  • Autistic disorder, Asperger’s syndrome, childhood disintegrative disorder and pervasive developmental disorder (not otherwise specified) will be collapsed into a single diagnosis of autism spectrum disorder.
  • Disruptive mood dysregulation disorder will be included to diagnose children aged 6 years or older who exhibit frequent outbursts of anger and persistent irritability three or more times a week for more than a year.
  • Posttraumatic stress disorder will belong to a new chapter on trauma- and stressor-related disorders. The criteria will expand to allow clinicians to more easily diagnose PTSD in patients.
  • Binge eating disorder and hoarding disorder will be recognized.
  • Substance abuse and substance dependence will combine to form the single category of substance use disorder.

Read the perspectives below from leading experts for more information on the development of the DSM-5 and how the new changes will affect clinical practice. These include Jan Fawcett, MD, on bereavement, Robert J. Hilt, MD, FAAP, on disruptive mood dysregulation disorder, Elspeth Cameron Ritchie, MD, MPH, on PTSD, Peter Tanguay, MD, on autism spectrum disorder, and B. Timothy Walsh, MD, on eating disorders.

Perspective
Jan Fawcett, MD

Jan Fawcett

  • Bereavement exclusion

    It seems to me that we removed the bereavement exclusion criterion because it didn’t make any clinical sense. First of all, grief has a totally different presentation than major depression. People who are grieving are focused on the loss of a loved one, they think about that loved one all the time, and they’re quite normally sad. It’s a specific syndrome that’s different from major depression. Those with major depression have other symptoms such as loss of pleasure, they have very negative feelings about themselves, loss of self-esteem, and they’re fatigued — so they have a syndrome very different from grief.

    Now, grief can precipitate a depression. When it does, we think the clinician, using his own judgment, should be able to diagnose and treat that condition whatever way the clinician thinks is necessary, which might be psychotherapy or some other treatment. Critics of this change say that everybody will treat patients with medication, but that’s not necessarily the case; we know that mild depressions don’t respond well to medications compared to placebo. They don’t separate — only severe depressions do. We thought it should be a clinical judgment, not something that was proscribed by a kind of Rube Goldberg-esq scheme.

    Firstly, we all know that grief lasts longer than 2 months. That was pulled out of the air. There was no evidence behind it that we can see. Secondly, people who develop major depression from or after bereavement respond the same way to treatment, even to medications, as people who develop depression that comes out of nowhere. Thirdly, we know people don’t just get upset over grief. If your house burns down, or if you get a letter from the Feds saying they’re going to arrest you for tax evasion, you would feel pretty bad, too, and that’s a normal reaction. We know that normal reactions make people sad — everyone knows that — but if the person gets into a state of a major depression and meets the criteria, we think it’s up to the clinician to use his or her own judgment to decide the appropriate treatment, and we wanted to prevent the clinician from making a diagnosis that doesn’t serve any purpose. That’s why we put a note in the text explaining all of this.

    So the question is, does the patient have a major depression or not, and what treatment does it require? We think clinicians can make that decision for themselves without all kinds of specific rules that were in the bereavement exclusion.

    • Jan Fawcett, MD
    • Editor, Psychiatric Annals
      Professor of Psychiatry, University of New Mexico School of Medicine
      Chair, DSM-5 Mood Disorders Work Group
Perspective
Robert J. Hilt, MD, FAAP

Robert J. Hilt

  • Disruptive mood dysregulation disorder

    The final diagnostic criteria for disruptive mood dysregulation disorder (DMDD) will not be released until May 2013, so the specifics about it are still unclear. However, what we do know is that this new DMDD diagnosis was inspired by the roughly 40-fold increase in pediatric bipolar disorder diagnoses over the past 10 years. The bipolar explosion is now thought to reflect both a specificity problem with the previous bipolar criteria and the difficulties clinicians have been having in finding alternative diagnoses to capture the problems being expressed by certain children. This has become a major problem in that very few of our current bipolar-labeled children (those who never had clear hallmark symptoms of multiple days-duration manic episodes) would have ever qualified for having the very long-term bipolar diagnosis as adults.

    The new DMDD diagnosis is hoped to return the bipolar diagnosis category to just those patients who have experienced hypomania and mania (and all of the associated future problems that come along with that), leaving the chronically irritable and recurrently highly disruptive children now being mislabeled as bipolar to be considered instead for a DMDD label. Agreed upon diagnoses are necessary to do research, so the next questions to arise will be about the diagnostic stability of DMDD, the functional differentiation of this category from other diagnoses like oppositional defiant disorder, the best treatment approaches for DMDD, and the outcomes predictions for a child who fits the DMDD criteria. There are many critics of this new diagnostic category, but I would recommend to reserve any final judgment until we see the final criteria and more studies about this new grouping can occur.

    • Robert J. Hilt, MD, FAAP
    • Psychiatric Annals Editorial Board member
Perspective
Elspeth Cameron Ritchie, MD, MPH

Elspeth Cameron Ritchie

  • Posttraumatic stress disorder

    The new posttraumatic stress disorder criteria have three critical changes. The first is the elimination of so-called criterion “A2.” This is the requirement that the individual experience fear, helplessness, and horror.

    The other major differences are in the addition of Criteria D and E. Criteria D adds mood and cognitive issues as part of the PTSD disorder. Specifically included are memory problems, feelings of guilt, and pervasive negative state. Criteria E adds irritability, impulsivity, and problems sleeping.

    The diagnosis is thus broadened, making it easier for clinicians to diagnose PTSD.

    The changes are consistent with what I have seen in soldiers and other service members returning from combat, who often 1) have not experienced fear, hopelessness, and horror, because of their military training; and 2) have anger, impulsivity and difficulty sleeping.

    Pharmacotherapy treatment may not change much, as currently SSRIs are usually already first-line agents. Likewise, recommendations to use the evidence-based psychotherapies — prolonged exposure and cognitive-behavioral therapy — probably will not change, at least not initially.

    More information about evidence-based treatment may be found in both the APA and DoD-VA PTSD guidelines.

    • Elspeth Cameron Ritchie, MD, MPH
    • Col., US Army (Ret.)
      Chief Medical Officer
      District of Columbia
      Department of Mental Health
Perspective
Peter Tanguay, MD, FACP

Peter Tanguay

  • Autism spectrum disorder

    No more Asperger’s. . . . He’s gone back to Austria and left no forwarding address. The same for PDD-Not Otherwise Specified. What are we to do? My advice: Fold these old diagnoses into the new all-in-one DSM-5 category of autism spectrum disorder.

    When Kanner first defined autism in 1943, he wrote:  “The outstanding, ‘pathognomic,’ fundamental disorder is the children’s inability to relate themselves ... to people and situations from the beginning of life.”  He did not single out deficient intellectual ability, unusual stereotypic behaviors, or anxiety or language handicaps as being fundamental symptoms of autism. The major characteristic of these children was that they did not relate.

    After a number of digressions (bad mothers cause their children to withdraw socially) and symptom accretions, the diagnosis of autism has returned to the concept of its being a social communication disorder. Other characteristics of autism, including language and intellectual deviations, symptoms of anxiety, ADHD, and obsessive-compulsive disorder, are important, but they should be listed under their respective DSM-5 domains. Fixated interests and repetitive behaviors remain as symptoms of autism in the DSM-5; but I predict they will eventually remain so only if they can be shown to be closely associated with a lack of social communication skills. Otherwise, they too will be shunted to another diagnostic category.

    The shift in autism diagnostic characteristics began in the 1970s when the nature and development of “social communication” came under investigation. Social communication skills are precisely what persons with autism fail to develop. When social communication skills were identified as having a normal distribution in the general population, autism could be hypothesized to represent the extreme end of the social communication spectrum. In another 50 years, when we understand the neurobiology of the “social brain,” we will develop a more precise diagnostic classification for autism, but until then I find the spectrum concept to be useful.

    • Peter Tanguay, MD, FACP
    • Spafford Ackerly Endowed Professor of Child and Adolescent Psychiatry (retired)
      Department of psychiatry and behavioral sciences
      University of Louisville School of Medicine
  • Disclosures: Dr. Tanguay reports no relevant financial disclosures.
Perspective
Timothy B. Walsh, MD

B. Timothy Walsh

  • Eating disorders

    The need to deal with two major issues drove many of the recommendations for change. First, a large number of individuals presenting for care with a clinically significant problem with eating behavior do not meet criteria for any of the diagnostic categories recognized by DSM-IV. In a number of studies, an eating disorder not otherwise specified (EDNOS) was the most frequent diagnostic category. This was the source of great frustration for individuals seeking care, who believed their problems had not been properly recognized, and for clinicians, who did not have an established diagnostic label to describe their patients’ difficulties.

    In order to reduce the frequency of EDNOS, several modest changes were recommended to the DSM-IV criteria for anorexia nervosa and bulimia nervosa. Furthermore, the Eating Disorders Work Group recommended that binge eating disorder, which was described in an appendix in DSM-IV, be formally recognized in DSM-5.

    Second, early in the course of the development of DSM-5, the importance of taking a life-span approach to all disorders was recognized. Most psychiatric disorders develop relatively early in life, often during childhood, adolescence, or young adulthood. Manifestations often change over time, and the disorder may not be recognized or come to clinical attention until later in life. In order to underscore these important phenomena, it was decided to eliminate the DSM-IV section titled ‘Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence.’

    As a result, three disorders in that section in DSM-IV, namely, pica, rumination disorder, and feeding disorder of infancy or early childhood, were reviewed by the Eating Disorders Work Group. Several changes were recommended to the criteria for pica and rumination disorder to reflect the fact that these disorders may be first recognized in adults.

    In addition, after substantial thought, study, and consultation with a number of experienced clinicians, the Eating Disorders Work Group recommended that feeding disorder of infancy or early childhood be expanded and that it be retitled avoidant/restrictive food intake disorder (ARFID).

    These comments have been excerpted from Dr. Walsh’s guest editorial in the November issue of Psychiatric Annals. Copyright ©2012, American Psychiatric Association. All Rights Reserved.

    • B. Timothy Walsh, MD
    • W&J Ruane Professor of Pediatric Psychopharmacology
      Columbia University Medical Center
      Chair, DSM-5 Eating Disorders Work Group

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