Perspective from Jan Fawcett, MD
Perspective from Robert J. Hilt, MD, FAAP
Perspective from Peter Tanguay, MD, FACP
Perspective from B. Timothy Walsh, MD
December 21, 2012
9 min read

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

Perspective from Jan Fawcett, MD
Perspective from Robert J. Hilt, MD, FAAP
Perspective from Peter Tanguay, MD, FACP
Perspective from B. Timothy Walsh, MD
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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.