DSM-5 Enters the Diagnostic Fray: Fifth Edition of the Widely Used Psychiatric Manual Focuses Attention on How Mental Disorders Should Be Defined

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To a cacophony of boos, so-whats and even a few cheers, the American Psychiatric Association released the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders, DSM-5, on May 18 at its annual meeting in San Francisco.

Controversy always flares when psychiatrists redefine which forms of human suffering will count as real and reimbursable by medical insurance. This time, though, the stakes are raised by competing efforts to classify mental disorders.

The World Health Organization plans to release a new version of its own system for identifying mental ailments in 2015 as part of the 11th edition of the International Classification of Diseases. It's not clear how much the ICD will mirror DSM-5.

Some differences have already emerged. Clinicians working on the international classification report in the May 11 Lancet that they plan to pare down the number and types of symptoms needed to diagnose post-traumatic stress disorder, or PTSD, and add a severe form of the condition triggered by long-lasting or frequent harrowing events. These departures from DSM-5 would make it easier for mental health workers to help victims of conflict and natural disasters in poor, non-Western countries, say psychologist Andreas Maercker of the University of Zurich and his colleagues.

Meanwhile, the National Institute of Mental Health in Rockville, Md., has launched the Research Domain Criteria, or RDoC, a 10-year effort to define mental disorders based on behavioral and brain measures. DSM's approach, by contrast, relies on rulings by groups of psychiatrists about which symptoms characterize particular disorders. The approach has yielded imprecise diagnostic labels that advance neither treatment nor research, argued psychiatrist and NIMH director Thomas Insel in an April 29 blog post.

Insel's statement raised hackles at the psychiatric association. On May 13, Insel and American Psychiatric Association president Jeffrey Lieberman together released a conciliatory statement declaring that DSM-5 and RDoC complement each other on the path to better diagnoses for mental disorders.

RDoC will fund research that examines how lots of factors--fear, attention, parenting styles and neighborhood qualities, to name a few--interact to produce symptoms that may or may not jibe with DSM-5 categories, said the RDoC project's director, psychologist Bruce Cuthbert, at the Association for Psychological Science annual meeting in Washington, D.C., on May 23. Not everyone with, say, autism spectrum disorder or PTSD has the same underlying problems, he says.

"RDoC is about understanding the biology and the psychology of mental illness," Cuthbert says. "DSM-5 is sloppy on both accounts."

DSM-5 has also gotten hammered--especially by psychiatrist Allen Frances, chair of the task force that produced the previous DSM--for allegedly turning some common forms of distress into medical conditions, encouraging physicians to prescribe unneeded psychoactive medications. …