The revision of the psychiatric bible

Getting a psychiatric diagnosis is be a mixed bag for most individuals. Some are relieved to know that their experience is one that can be identified, that someone has made sense of it, that it is known and therefore may have resolution. Others may fall apart as it hits the dreaded bull’s eye, signifying a connection to a crazy relative or an impending psychosis. Some see it as salvation; some see it as condemnation. 

The publication of the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in May 2013 is both eagerly anticipated and dreaded. This 950+ page manual is used by psychiatrists, psychologists, counselors and layman alike to categorize and understand mental and behavioral health disorders.

The most recent revision of the DSM resulted in the DSM-IV-TR, primarily text changes updating and/or expanding on disorders already agreed upon by the committee.  The last major revision of the DSM was in 1994.  

Proposed major changes to the diagnostic categories include:

• Austistic Disorder and Asperger’s Disorder would be consolidated under Austism Spectrum Disorders. These disorders would no longer be seen as separate. While supporters suggest that this may provide less narrow criterion for meeting a diagnosis, critics argue that this potentially leads to the potential for more people to meet a particular diagnosis and thus lead to overmedication or unnecessary stigmatizing.
• The ten current Personality Disorders would be reformulated as Personality Disorders with five levels of severity and six trait domains. Supporters are encouraging this move as a way to de-stigmatize disorders such as Borderline Personality Disorder, a disorder which many practitioners turn away due to its difficult to treat nature. Critics argue that the ten current categories of personality disorder are indeed separate, and while they share a foundation, they are not alike in their construction.
• Substance-Related Disorders have previously been classified by a) the substance and b) abuse or dependence.  The new formulation eliminates the specific classifier of usage, using instead the substance name followed by -use Disorder (i.e., Alcohol-use Disorder). Current research does not agree on when dependence/addiction occurs.  No changes were made to the diagnoses of substance intoxication or withdrawal, nor were changes made to disturbances subsequent to the use of a substance (i.e., Caffeine-induced Sleep Disorder, Cocaine-induced Mood Disorder).
• In Mood Disorders, there are several changes but the one most illustrative of how mental health has evolved is the addition of Mixed Anxiety Depression. Clinicians have long suggested this as a separate diagnosis so its’ inclusion appears to be largely uncontested and supported.
• Hoarding Disorder is also slated as a possible addition to the DSM-V. This disorder would be added under Anxiety Disorders.
• Another proposed change for the DSM is the Psychosis Risk Syndrome. This appears to be the most controversial proposal since its aim is to identify those at risk for later development of a psychotic disorder such as schizophrenia. Critics state concern that this diagnosis might unfairly stigmatize individuals. Most research into psychotic disorders tends to be retrospective wherein individuals are later recalled as ‘strange’ or having ‘unusual behavior’.  

The Diagnostic and Statistical Manual of Mental Disorders (DSM) undergoes reformulation approximately every ten years. Committees of medical doctors, psychologists, and public health officers. Each member is allowed up <$10,000 from pharmaceutical companies and is not allowed to hold >$50,000 in stocks aggregate to pharmaceutical companies.  

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Mental health parity comes to pass this summer. The DSM-V revision will be approved close to this time. Although the diagnostic use of the DSM should not be tied to insurance reimbursement, approval, or even insurance use period, it is. Insurance companies routinely deny approval for ‘less serious’ mental health diagnoses such as an adjustment disorder or an anxiety disorder. How these changes might affect insurance reimbursement/usage has yet to be seen.

Cultural and gender issues are also said to be considered in the reformulation of the DSM. However, little to no information is found on the official website.

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A mental health diagnosis is weighted. In the military, a diagnosis of a Personality Disorder earns an automatic discharge.  A person who has been diagnosed with a Mood Disorder (i.e. depression) can later be denied coverage for a new insurance policy.  An insanity plea is based on a diagnosis that pulls from the Diagnostic and Statistical Manual of Mental Disorders. 

Our culture now makes entertainment of diagnoses. Witness: Hoarders wherein we are invited into the homes of those who cannot bear to part with anything; House has episodes of hypochondriacs and Munchausen’s; there is a reality show featuring a realtor with Obsessive Compulsive Disorder. We make entertainment out of pain. Surely there is a diagnosis for that?

References:  DSM-5: The Future of Psychiatric Diagnosis; Psychiatry's DSM undergoes major revision

The committees for the DSM revisions are welcoming input and feedback from the public at the above (2nd) web address.