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Tuesday, February 16, 2010

DSM-V: Change We Can Believe In?

So the draft of DSM-V is out.

If, as everyone says, the Diagnostic and Statistical Manual is the Bible of Psychiatry, I'm not sure why it gets heavily edited once every ten years or so. Perhaps the previous versions are a kind of Old Testament, and only the current one represents the New Revelation from the gods of the mind?

Mind Hacks has an excellent summary of the proposed changes. Bear in mind that the book won't be released until 2013. Some of the headlines:
  • Asperger's Syndrome is out - everyone's going to have an "autistic spectrum disorder" now.
  • Personality Disorders are out - kind of. In their place, there's 5 Personality Disorder Types, each of which you can have to varying degrees, and also 6 Personality Traits, each of which you can have to varying degrees.
  • Hypoactive Sexual Desire Disorder - the disease which failed-antidepressant-turned-aphrodisiac flibanserin is supposed to treat - is out, to be replaced by Sexual Interest and Arousal Disorder.
  • Binge Eating Disorder, Hypersexuality Disorder, and Gambling Addiction are in. Having Fun is not a disorder yet, but that's on the agenda for DSM-VI.
More important, at least in theory, are the Structural, Cross-Cutting, and General Classification Issues. This is where the grand changes to the whole diagnostic approach happen. But it turns out they're pretty modest. First up, the Axis system, by which most disorders were "Axis I", personality disorders which were "Axis II", and other medical illnesses "Axis III", is to be abolished - everything will be on a single Axis from now on. This will have little, if any, practical effect, but will presumably make it easier on whoever it is that has to draw up the contents page of the book.

Excitingly, "dimensional assessments" have been added... but only in a limited way. Some people have long argued that having categorical diagnoses - "schizophrenia", "bipolar disorder", "major depression" etc. - is a mistake, since it forces psychiatrists to pigeon-hole people, and that we should stop thinking in terms of diagnoses and just focus on symptoms: if someone's depressed, say, then treat them for depression, but don't diagnose them with "major depressive disorder".

DSM-V hasn't gone this far - the categorical diagnoses remain in most cases (the exception is Personality Disorders, see above). However, new dimensional assessments have been proposed, which are intended to complement the diagnoses, and some of them will be "cross-cutting" i.e. not tied to one particular diagnosis. See for example here for a cross-cutting questionnaire designed to assess common anxiety, depression and substance abuse symptoms.

Finally, the concept of "mental disorder" is being redefined. In DSM-V a mental disorder is (drumroll)...
A. A behavioral or psychological syndrome or pattern that occurs in an individual

B. The consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning)

C. Must not be merely an expectable response to common stressors and losses...

D. That reflects an underlying psychobiological dysfunction

E. That is not primarily a result of social deviance or conflicts with society
The main change here is that now it's all about "psychobiological dysfunction", whereas in DSM-IV, it was about "behavioral, psychological, or biological dysfunction". Hmm. I am not sure what this means, if anything.

But read on, and we find something rather remarkable...
J. When considering whether to add a mental/psychiatric condition to the nomenclature, or delete a mental/psychiatric condition from the nomenclature, potential benefits (for example, provide better patient care, stimulate new research) should outweigh potential harms (for example, hurt particular individuals, be subject to misuse)
This all sounds very nice and sensible. Diagnoses should be helpful, not harmful, right?

No. Diagnoses should be true. The whole point of the DSM is that it's supposed to be an accurate list of the mental diseases that people can suffer from. The diagnoses are in there because they are, in some sense, real, objectively-existing disorders, or at least because the American Psychiatric Association thinks that they are.

This seemingly-innocuous paragraph seems to be an admission that, in fact, disorders are added or subtracted for reasons which have little to do with whether they really, objectively exist or not. This is what's apparently happened in the case of Temper Dysregulation Disorder with Dysphoria (TDDD), a new childhood disorder.

TDDD has been proposed in order to reduce the number of children being diagnosed with pediatric bipolar disorder. The LA Times quote a psychiatrist on the DSM-V team:
The diagnosis of bipolar [in children] "is being given, we believe, too frequently," said Dr. David Shaffer, a member of the work group on disorders in childhood and adolescence. In reality, when such children are tracked into adulthood, very few of them turn out to be bipolar, he said.
And the DSM-V website has a lengthy rationale for TDDD, to the same effect.

Now, many people agree that pediatric bipolar is being over-diagnosed. As I've written before, pediatric bipolar was considered to be a vanishingly rare disease until about 10 years ago, it still is pretty much everywhere outside the USA.

So we can all sympathize with the sentiment behind TDDD - but this is fighting fire with fire. Is the only way to stop kids getting one diagnosis, to give them another one? Should we really be creating diagnoses for more or less "strategic" purposes? When the time comes for DSM-VI, and the fashion for "pediatric bipolar" has receded, will TDDD get deleted as no longer necessary? What will happen to all the "TDDD" kids then?

Can't we just decide to diagnose people less? Apparently, that would be a rather too radical change...

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