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Psychology, Philosophy & Real Life

Dr George Simon, PhD

Big Changes Coming for Psychiatric Diagnoses

The DSM-V, expected to be published next year, will herald changes in the way clinicians conceptualize psychopathology and diagnoses. There is a trend towards more of a “developmental” and a “dimensional” approach to human nature.

Photo by BryanKemp - //flic.kr/p/cjuTE
Photo by BryanKemp - http://flic.kr/p/cjuTE

It’s been several years in the making, but it now appears that the fifth edition of the manual most psychiatrists and other mental health professionals use to diagnose clinical conditions will be rolling off the presses sometime next spring, possibly in May. And perhaps no revision to the Diagnostic and Statistical Manual of Mental Disorders (commonly referred to as the DSM) has sparked as much debate among the various interested parties and stakeholders as the DSM-V.

But even after all the critiquing, editing, clarification, and correction has ended, the new edition of the “psychiatric bible” is likely to generate controversy for some time to come because of some sweeping changes not only in certain diagnostic categories, but also in the very manner in which the new manual will try to encourage clinicians to conceptualize various illnesses.

Perhaps the single most distinguishing characteristic of the DSM-V will be the “developmental approach” it takes to understanding mental illnesses in general, and how each illness might manifest itself throughout an individual’s lifespan. (Reference: Darrel A. Regier, William E. Narrow, Emily A. Kuhl, and David J. Kupfer, eds (2011) The Conceptual Evolution of DSM-5. Arlington, Virginia: American Psychiatric Publishing [Amazon-US | Amazon-UK].) And while this approach holds great promise for increasing our awareness about how various conditions develop, critics argue that as the text is currently written, there is great potential for diagnostic inaccuracy. For example, a child who exhibits “temper tantrums” might actually be manifesting the frustration that accompanies the social interaction skills deficits common to individuals laboring under an Autistic Spectrum Disorder. Such behavior could also be associated with an underlying depression or possibly even an emerging Bipolar Disorder. Then again, the tantrums could represent nothing more than a “normal” phase of development (e.g. a behavior that all children at some point in their development and learning process “test out” as a strategy for expressing themselves and handling stressful situations). And therein lies the dilemma facing clinicians who will be using the new manual. Because of the broad criteria for diagnosing “disruptive mood dysregulation disorder,” a relatively common behavior in children could be erroneously categorized as a significant mental illness requiring medical intervention. For these reasons, firm grounding in normal human development as well as the wide range of true psychopathology will be essential for professionals using the manual.

Based on suggestions from various research teams (e.g., A Dimensional Approach to to Developmental Psychopathology by James J. Hudziak, et al.), the DSM-V also adopts a “dimensional” approach to human functioning. From this perspective, every personality is unique in his or her attributes along various dimensions. Viewing each individual not only along all the various dimensions of their personality, but also within the context of their developmental maturity, should help clinicians better assess to what extent true pathology is present, as opposed to developmental immaturity of some type and degree.

As has been the case with prior editions, the proposed new manual has sparked new concern about the potential for diagnostic inflation and over-prescribing of psychotropic medications. Clinicians today face pressures from many sources (e.g. parents, intolerant spouses, schools, and most especially, insurance companies) to find fast-acting and reliable remedies for various problems. And psychotropic medications of various types can indeed produce some fairly dramatic behavioral changes in patients who take them. The use of these medicines has to be justified, putting pressure on clinicians to place a diagnostic label on their patients commensurate with the type of intervention prescribed to them. Often, this leads to the kind of over-diagnosing that we have recently witnessed with conditions like Bipolar Disorder. And because the new edition of the DSM broadens the criteria for the diagnoses of many conditions, critics fear that over-diagnosing and over-prescribing might potentially become even greater problems than they already are. Furthermore, clinicians frequently help individuals who struggle with difficult life circumstances and who benefit from professional counsel, but who do not rightfully warrant a true psychiatric diagnosis. Insurance companies most often won’t pay for a service that carries a “no diagnosis” verdict, so, faced with pressure to apply at least some diagnosis to a problem they’re addressing, and being presented with broader criteria by which to make a diagnosis, it’s quite possible clinicians will be more tempted than ever to over-pathologize.

Whatever shape the final product takes, the DSM-V will revolutionize the conceptualization of many disease processes. Instead of the distinct diagnosis of Autism or Asperger’s Disorder, the category of “Autistic Spectrum Disorder” will not only capture the wide range of this developmental delay, but also reflect our more up-to-date understanding of neurobiological variations. And Binge Eating Disorder will be afforded a more formal diagnostic status (instead of being listed in the appendix) because of all the evidence that has accumulated about its characteristics and tendency to run in families. Big changes are also in store for the personality disorders (the fact that Narcissistic Personality Disorder or NPD is likely to be “de-frocked” has many up in arms). (This topic was discussed in a recent post: “Psychological Paradigm Shift: The Beauty of the Old and Need for the New”.) Perhaps most strikingly, a category has been created for Suicidal Behavior Disorder, in part because of the mounting evidence that such behavior is not restricted to bouts of severe depression or the consequence of severe personality disorder.

A lot of training will be required for clinicians to use the new diagnostic manual wisely and correctly. And partly for that reason, a task force is working on a different version of the manual that can be more easily understood and correctly employed by general practitioners. Still, it will take many months, if not years of use to tell whether the latest edition of the DSM achieves its goal of helping professionals (mental health specialists and general practitioners alike) better understand, correctly diagnose, and adequately treat their patients’ psychological problems.

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