Go to an ER complaining of chest pain and you are whisked away for an EKG and blood tests to check for certain enzymes that indicate a heart attack is in process or has already occurred. But if your major complaint is anxiety or significant mood swings, diagnosis is not so easy.
Though progress is being made in identifying genetic biomarkers for mental illnesses, and brain scans are showing marked differences between people with and without certain mental disorders, since 1952 the gold standard used to diagnose and differentiate psychiatric conditions is the Diagnostic and Statistical Manual of Mental Disorders, or DSM.
The newest version, the DSM-5, which was released Saturday during the American Psychiatric Association (APA) convention in San Francisco, has been surrounded with controversy.
Concerns were voiced long before the manual was approved by the APA, its publishing body. One of the most vocal critics is psychiatrist and Duke University Professor Emeritus Dr. Allen Frances. He chaired the DSM-IV Task Force that oversaw revisions to the DSM-III.
He and other critics say DSM-5 (this is the first manual with a number rather than a Roman numeral in its title) has added new illnesses and redefined or re-categorized several existing ones that will lead to over-diagnoses; increased prescribing of medications, particularly in children; and pathological labeling of certain normal behaviors.
“New diagnoses in psychiatry are more dangerous than new drugs because they influence whether or not millions of people are placed on drugs — often by primary care doctors after brief visits. Before their introduction, new diagnoses deserve the same level of attention to safety that we devote to new drugs,” Frances wrote in a Dec. 2 Psychology Today article.
Among some of the more controversial changes in the DSM-5:
•A new pediatric mental condition, Disruptive Mood Dysregulation Disorder (DMDD), applies to children, ages 6 to 18, who have temper tantrums three or more times a week for a year. Critics say this is just one more diagnosis that will lead to increased drug prescribing.
Other mental-health providers embrace the diagnosis, saying it will reduce pharmacological treatment because many of the children who fit DMDD criteria are being diagnosed with bi-polar disorder and given heavy-duty mood stabilizing drugs.
•In the DSM-IV, bereavement was excluded from the diagnostic criteria for depression. In the DSM-5, bereavement can qualify for a diagnosis of depression.
•A person who overeats 12 times in three months can be labeled with Binge Eating Disorder.
•Mild Neurocognitive Disorder has been added as a diagnosis for people with age-related memory loss that is not to the level of dementia. Frances maintains the new diagnosis will be overused and create angst in people who are aging normally.
But Ron Williams, a neuropsychologist with Fort Wayne Neurological Center, says this diagnosis is needed to help identify people at risk of developing Alzheimer's. Early detection will help scientists advance early interventional treatments.
•No longer do Asperger's syndrome, pervasive developmental disorder (PPD) and other subcategories of autism exist; just one diagnosis, autism spectrum disorder (ASD), is in the DSM-5.
Lumping the disorders together may lead to loss of special education and treatment services for some children. Indeed, one Yale University study concluded up to 40 percent of children meeting criteria for autism spectrum under DSM-IV will fail to meet DSM-5 criteria, according to the Journal of the American Academy of Child and Adolescent Psychiatry.
Benefits and problems
Though Fort Wayne psychologist Barb Gelder has no major beef with the DSM-5, like most providers, she has not had time to digest the new manual. She is encouraged by a paradigm shift from behavioral-focused diagnostic criteria to now taking into account the environment, how a child is parented and other psychosocial factors.
“What they are starting to do, I think, is to try to go back to how we used to think about people, which is much more developmentally. They are getting away from the behavioral stuff and looking at things more comprehensively, more holistically,” Gelder says.
The National Institute of Mental Health (NIMH) and the British Psychological Society are among major organizations with outspoken opposition to DSM-5, saying it is an outdated tool that lacks scientific validity.
NIMH director Dr. Thomas Insel announced just prior to the DSM-5's release that the institute will no longer fund research based on DSM criteria. Instead a new Research Domain Criteria already under development will use genetics, imaging and other scientifically-generated data to create a new diagnostic classification system.
Dr. Alan Breier, professor of psychiatry at IU School of Medicine in Indianapolis, agrees better diagnostic tools are needed.
“Our goal is to have more meaningful biological-based, brain-based tools,” Breier said. “There's a lot of exciting research in this area, a lot of promising measures. The work is very impressive. But is it ready today to apply in a clinic? No.”
But if providers want to be paid by insurers, they must continue using the DSM, he points out.
“We'll be using the DSM in the clinic for sure for the foreseeable future. As the work of (NIMH) matures and develops, we'll see the beginning of augmenting the DSM tool. Someday,” Breier says, “we may not need the DSM anymore.”