Friday, May 17, 2013

Defense of the DSM-5: New diagnoses for picking, bingeing, and tantrums. - Slate Magazine

Several new diagnoses appear in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, released later this month, and critics are attacking with claws extended. Controversy surrounds whether several of these new disorders should be included, and many experts question their validity.
Even Allen Frances, psychiatry professor emeritus at Duke University, who chaired the task force for the previous edition, the DSM-IV, called the day on which the DSM-5 was approved "a sad day for psychiatry." Of greatest concern is the new manual's potential to over-pathologize human behavior.
One of the most controversial new diagnoses, which Slate has covered before, is Disruptive Mood Dysregulation Disorder. It is intended to describe children between 6 and 18 years of age who show some signs of potential childhood-onset bipolar disorder. The category's hallmark criteria are "temper outbursts that are grossly out of proportion in intensity or duration to the situation." Yes, that's right. It sounds like temper tantrums.
Another controversy has erupted around Binge Eating Disorder. Bingeing, or eating a large quantity of food in a shorter period of time than is typical, is a disordered behavior according to theDSM-5. An individual who has eaten excessively at least 12 times in a period of three months meets criteria for Binge Eating Disorder. Frances calls Binge Eating Disorder one of the "top 10 changes to be ignored," noting that bingeing is "no longer just a manifestation of gluttony and the easy availability of really great tasting food.DSM has instead turned it into a psychiatric illness." (In fairness, bingeing is not a novel concept. It was previously listed as one of a number of potential symptoms used to diagnose a range of eating disorders, or it could be identified on its own as falling into the category Eating Disorder Not Otherwise Specified.)
It's unclear what the new diagnostic criteria mean for most people. It could mean that children with temper tantrums (that would be most kids, right?) could potentially be evaluated and/or treated for a psychiatric illness. Tantrums may become more than tantrums, but rather potential symptoms of mental illness. Anyone who eats like it's Thanksgiving a few too many times within a few months may be considered mentally ill.
However, there's more to this than simply saying our culture is moving toward pathologizing normal behavior. The DSM-5's heart is in the right place. In many cases the authors of the new manual have added categories to keep people from being wrongly labeled with a more severe disorder. Having the category Disruptive Mood Dysregulation Disorder may deter clinicians from prematurely diagnosing bipolar disorder, a serious mental illness with associated stigma that is often treated with medications that carry a host of potentially significant adverse effects.
The DSM-5 also adds skin picking (Excoriation Disorder) to its list of new diagnoses, which is characterized by repetitive skin picking that results in lesions, accompanied by recurrent unsuccessful attempts to cease the behavior. Critics have asserted that everyone picks their skin as a normal part of grooming behavior and turning such a behavior into a psychiatric illness will result in the inappropriate diagnosis of many normal individuals with normal behaviors. But skin picking is more than popping a few pimples. Yes, everyone picks at his or her skin at some point; however, skin picking as a disorder extends to picking, scraping, or gouging that results in scarring or disfigurement.
I see patients who struggle with skin picking, and they are seeking therapy because it has started to interfere with their ability to have a normal life.  It's important to remember that the DSM-5 is written for clinicians who are seeing patients with a set of troublesome symptoms. It's not a catalog for the general public to browse through in order to identify problems in themselves or others. Binge Eating Disorder has been included for the benefit of a therapist seeing a patient who worries about his binge eating and its negative impact on his life, not to pathologize everyone at an all-you-can-eat restaurant.
Many of the critiques coming from nonprofessionals treat the DSM-5 as the be-all and end-all tool for evaluating mental health and charging for mental health care. Actually, though, it isn't. Health care providers are tied to a different manual for billing and coding purposes, theInternational Classification of Diseases, Ninth Revision. It is actually this manual that diagnoses call home. Without it, insurance companies will not process claims for payment. The ICD-9 codes are largely consistent with those of DSM-IV, but with the release of DSM-5, there is likely to be confusion and billing issues. Incidentally, ICD-10 will not be released until 2014. Some frustrated clinicians are contemplating whether they will pay any attention to theDSM-5's release and, instead, may continue to use the DSM-IV/ICD-9 coding system. This may be merely their own disgruntled resistance to change.
The revolt against the DSM-5 has culminated in a bold, yet not unexpected, statement by Thomas Insel, the director of the National Institute of Mental Health. Insel's Director's Blog entry on April 29 expressed his displeasure with not only DSM-5 and its unwelcome additions, but also the DSM's symptom-based categorical approach as a whole.  He noted that the long-standing goal of the DSM as a diagnostic tool is to provide clinicians with a common language for psychopathology, and it continues to meet that goal. However, in an era of dramatic advancements in neuroscience and genetics, the DSM's approach to diagnosis has become outdated, relying on clusters of observable symptoms rather than lab tests. He asserts that as medical diagnosis has advanced, the growth and maturation of psychiatric diagnosis has been stunted.  In fact, of the DSM-5, Insel writes, "It is, at best, a dictionary, creating a set of labels and defining each," noting that although the DSM's common language creates a certain "reliability," "[t]he weakness is its lack of validity." 
Although Insel's statement came as a surprise to some, the NIMH has been working for several years to develop a set of criteria for the development of a new system for classifying mental illness. It just so happens that this may be a convenient time to gain support and momentum for NIMH's newly launched Research Domain Criteria project. Its goal will be "to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system."  What does this really mean? It means that NIMH will no longer be adhering to specific sets of diagnostic criteria for inclusion in its studies and will be relying more heavily on "hard science" data for the identification of specific psychiatric illnesses.  It will be "re-orienting its research away from DSM categories." 
Ask clinicians how long the DSM-5 was in the works, and they are likely to joke about the painstaking wait for this lackluster manual. The project started in 1999 and involved 28 Task Force members, 13 Work Groups, 160 health care professionals, and more than 300 outside advisers.
Saying that it took many more years than anticipated would be a vast understatement.  However, it's difficult to even fathom the probable wait that the mental health field has to endure for the Research Domain Criteria's labor to come to fruition. I hope I am alive to see it. And I hope it's worth the wait.  For now, I'm still hovering over the purchase button toorder my new DSM-5.