Diagnosing the Diagnostic and Statistical Manual of Mental Disorders

Fifth Edition

Rachel Cooper

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429912672
• Edition: 1
• Topic: Psicologia
• Subtopic: Storia e teoria della psicologia

The Diagnostic and Statistical Manual of Mental Disorders, more commonly known as the DSM, is published by the American Psychiatric Association and aims to list and describe all mental disorders. The publication of DSM-V in 2013 brought many changes. Diagnosing the Diagnostic and Statistical Manual of Mental Disorders is written for all those who wonder whether the DSM-V now classifies the right people in the right way. It is aimed at patients, mental health professionals, and academics with an interest in mental health.

Issues addressed include:

• What are the main changes that have been made to the classification?
• How is the DSM affected by financial links with the pharmaceutical industry?
• To what extent were patients involved in revising the classification?
• How are diagnoses added to the DSM?
• Does medicalisation threaten the idea that anyone is normal?
• What happens when changes to diagnostic criteria mean that people lose their diagnoses?
• How important will the DSM be in the future?

Chapter One
DSM-5: an overview of changes

These days, as soon as one edition of the DSM goes to press, work on the next begins. The revision process that culminated in the publication of DSM-5 thus started long ago; with pipe dreams that finally came to nothing. An early publication, A Research Agenda for DSM-V (the Latin numerals only changed later) set out the ambitions (Kupfer, First, & Regier, 2002). A Research Agenda for DSM-V is an extraordinary document. The book doesn’t consist of plans for DSM-5 but rather of plans for plans; a series of “white papers” outline research priorities in various areas relevant to psychiatric classification. It is a testament to the phenomenal success of the DSM that such a book should be published, and not only published but published in paperback; research proposals related to psychiatric classification now find a mass readership. The very term “white paper”, used by the editors to describe the chapters, is more normally associated with plans produced by the offices of nation states. Though partly bluster, such self-importance is basically justified. Given that millions of people worldwide suffer from mental disorders, and that the DSM diagnosis someone receives can determine whether and how they are treated, changes to the DSM can potentially affect the lives of as many people as changes in the policies of most countries.

In retrospect perhaps unwisely, A Research Agenda for DSM-V begins by detailing problems with the DSM series to date. The DSM-III, published in 1980, sought to be a purely descriptive classification that made no use of unproven theoretical assumptions (APA, 1980, pp. 6–8). At the time, psychoanalysis remained an important perspective in US psychiatry, and psychoanalytically and biologically inclined psychiatrists could reach agreement on little. It was hoped that producing a theory-free classification would make the DSM acceptable to mental health professionals working within different theoretical frameworks. A key theme of A Research Agenda for DSM-V is that the descriptive syndromes included in the DSM have now become so embedded in psychiatric research as to be potentially problematic. It increasingly seems likely that some theoretically interesting populations do not map on to DSM categories, and such groups are currently under-researched. If, for example, some sub-group of those with a particular DSM diagnosis share a genetic abnormality, or a drug can help a population that cuts across current categories, this is likely to be missed by current research programmes. Unfortunately, while A Research Agenda for DSM-V is clear that research based on DSM-IV-like categories might well make little progress, it is less clear about what the DSM-5 should offer instead, opining only that some “as yet unknown paradigm shift may need to occur” (Kupfer, First, & Regier, 2002, p. xix). While the chapters of A Research Agenda for DSM-V boast about the great advances being made in areas such as neuroscience, developmental science, and cross-cultural studies, each also makes it clear that robust findings that might support a fundamentally different approach to psychiatric classification are a long way off.

In the event, between the publication of A Research Agenda for DSM-V (2002) and the publication of DSM-5 (2013) the APA did not develop a new paradigm for psychiatric classification. In place of a paradigm shift, the DSM-5 offers a chapter reorganisation. In a Research Agenda for DSM-V there is much talk of moving towards more dimensional approaches to classifying psychopathology. In the end, efforts to construct a dimensional system failed, but the new organisation of disorders in the DSM-5 is supposed to hint at a more dimensional approach. Disorders that are thought to have a similar origin are now placed together in the classification. This organisation is supposed to be “a bridge to new diagnostic approaches” (APA, 2013, p. 13). The idea is that placing disorders thought similar adjacent to each other will help emphasise the commonalities that run across the diagnostic categories. The categories will thus seem less categorical than under previous organisations, and the APA hopes that this will encourage “broad investigations within the proposed chapters and across adjacent chapters” (APA, 2013, p. 13).

As one might guess from the fact that an anticipated paradigm shift became a chapter reorganisation, the DSM-5 is conservative in outlook. When considering changes to the diagnostic criteria, I shall generally compare the DSM-IV (1994) and the DSM-5. The DSM-IV-TR (2000) was only a “text revision”, that is the sets of diagnostic criteria remained the same as in the DSM-IV (with a very few exceptions), and only the accompanying text was revised. Changes in the sets of diagnostic criteria between the DSM-IV and DSM-5 are modest. A few new disorders have been included; a few have been removed. Some diagnostic criteria have changed. One of the issues this book will explore is how it is that making revisions to the DSM has become so very difficult that conservatism tends to prevail. I will also show how it is that each and every small change can matter. When it comes to classification the devil is in the details.

The most controversial changes to the DSM concern possible expansion of the classification. When a new diagnosis comes to be included in the DSM, or an old category is expanded, more people come to be thought of as suffering from mental disorder. The effects of this are multiple, and not all are benign. As Peter Conrad (2007) and other medical sociologists have done so much to show, with diagnosis, the ways in which patients, and others, think about a problem shifts. Diagnosis suggests that the source of a problem should be located within an individual, and indicates that professional medical help is likely to be required. Simultaneously, diagnosis tends to remove an issue from the political or ethical domain. To take an example, consider the effects of the diagnosis of attention deficit/ hyperactivity disorder (ADHD). Prior to the omnipresence of ADHD diagnoses, one could imagine many different explanations for the activity of disruptive children. Maybe the teachers are boring? Maybe young children are naturally ill suited to spending days cooped up studying maths? Maybe the problem is simple naughtiness? Maybe contemporary parenting styles are somehow inadequate? Diagnosis with ADHD acts to push these competing explanations to one side. The education system, parents, and the children themselves tend to be absolved from blame. Instead the cause of the disruption is located inside the children’s brains, and the remedy frequently proposed is drug treatment.

Some difficulties are caused by problems inside brains, drugs sometimes work, and diagnosis can sometimes be useful. But it is important to remember that diagnosis also produces harm. Not only does an emphasis on medical interventions distract attention from political, economic, and moral changes that might produce preferable results, but also drugs can be overused and have side effects, and stigma and self-stigmatisation can reduce the life opportunities for the diagnosed. As medicalisation has such effects, no expansion of the domain of mental disorder should pass unexamined.

Inclusions to the DSM come in different grades. Most straightforwardly, some new additions make it into the manual proper. These disorders have their own numerical codes and sets of diagnostic criteria and are “fully legitimate” diagnoses.

Other additions have a less clear status. Since DSM-III-R, the DSM has included an appendix listing “Conditions for further study”. Conditions in the appendix lack numerical codes, but do have sets of diagnostic criteria. The appendix acts as a halfway house for conditions not yet seen to be fully legitimate for inclusion in the main manual. In the DSM-5, a note states these diagnoses are considered appropriate for research, but not for clinical practice.

There are also some diagnoses that are mentioned in the text of the DSM but that have no accompanying diagnostic criteria sets. The DSM is littered with “ragbag” codes for “other” disorders, for example “other specified anxiety disorder”, “other specified feeding or eating disorder”. These are provided for patients who the clinician considers to suffer from a disorder of some particular genus but who fail to meet the criteria for any specific coded diagnosis. Sometimes new disorders first make it into the DSM through being listed in the text of the DSM as possible “other” disorders that might appropriately fall under these ragbag codes. For example, restless legs syndrome has been included as a distinct codable condition for the first time in DSM-5, but was previously described in the text of the DSM-IV as an example of dyssomnia not otherwise specified.

With the DSM-5, conditions that have been introduced to the main body of the classification include, perhaps most controversially, disruptive mood dysregulation disorder, for children with persistent irritability and episodes of behavioural dyscontrol. In the US there has recently been a massive increase in the numbers of children being diagnosed with bipolar disorder. Disruptive mood dysregulation disorder is intended as a more accurate label for these children. It will be discussed in greater detail in Chapter Two.

Other additions include social (pragmatic) communication disorder, a developmental disorder characterised by problems with the social use of language (to be discussed in greater detail in Chapter Five). Binge eating disorder has been upgraded from the appendix, and is as it sounds, a diagnosis for people who binge eat. Excoriation (skin picking) disorder is a new diagnosis, for people who repeatedly pick their skin. In addition to restless legs, rapid eye movement sleep behaviour disorder is another sleep disorder previously only mentioned in the text but now supplied with diagnostic criteria. Hoarding was previously mentioned in the DSM-IV as a possible symptom of obsessive-compulsive personality disorder but is now seen as characterising a distinct condition. Chapter Four will discuss hoarding disorder in greater detail and examine further how it is that new conditions can come to be included in the DSM.

Premenstrual dysphoric disorder, a mood disorder related to the menstrual period (upgraded from the appendix), is a further notable addition. During the construction of the DSM-III, III-R, and DSM-IV this disorder (and its ancestors with different names) was one of the most controversial suggestions for inclusion (for a history of these debates see Caplan, 1995). Then, massive protests by feminists, who feared that it would pathologise normal changes in mood associated with the menstrual period, blocked its inclusion in the main classification. The APA archives contain folders and folders of protest letters. This time round, the upgrading of the disorder to the main body of the classification has passed with little comment.¹

Amongst new conditions included in the appendix the most controversial are attenuated psychosis syndrome and internet use gaming disorder. Attenuated psychosis syndrome is conceptualised as a condition characterising adolescents at increased risk of developing schizophrenia. Critics worry that this diagnosis may lead to the stigmatisation and over-treatment of peculiar teenagers (Moran, 2009). Internet use gaming disorder concerns some who see it as opening the door to a proliferation of other, behaviour-related “addictions” (sex addiction, exercise addiction, etc.) (Frances, 2013, pp. 188–192).

The domain of psychiatry can also expand as a result of changes to the sets of diagnostic criteria for existing diagnoses. In the DSM-5 numerous small changes, of which I will discuss only a few, may be expected to result in more people being diagnosed with particular conditions. For example, the diagnostic criteria for ADHD have changed to make it easier for adults to receive the diagnosis. Previously symptoms had to have their onset prior to age seven, now the age threshold has been increased to twelve, and the number of symptoms that adults require for diagnosis has also been reduced. In DSM-IV bulimia nervosa and binge eating required binges twice a week for three months, now binges need occur only once a week.

Amongst the most controversial changes to the diagnostic criteria has been the removal of the “grief exclusion” in major depressive disorder (Friedman, 2012; Lancet, 2012). Symptoms of bereavement can be similar to those of depression. In DSM-IV, depression could not be diagnosed in recently bereaved people (unless the symptoms were very severe or lasted longer than two months). In DSM-5 the grief exclusion has been removed, although a footnote, added in response to protests, gives guidance as to how a clinician can distinguish between grief and a major depressive episode, and seeks to ensure that only some bereaved people will be diagnosed as depressed.

Most of the changes to diagnostic criteria are carefully considered by the relevant committees (though they may well remain controversial), but on occasion diagnostic expansion occurs by mistake. In The Book of Woe (2013), Gary Greenberg interviews Allen Frances, who was chairperson for the DSM-IV and DSM-IV-TR. Frances is now haunted by some of the accidental consequences of the revisions he oversaw. Paraphilias (sexual perversions) were amongst a handful of disorders where diagnostic criteria were changed between DSM-IV and DSM-IV-TR. The result was “one royal fuckup” (to quote Frances) (Greenberg, 2013, p. 233). In DSM-IV, paraphilias could only be diagnosed if the patient experienced “clinically significant distress or impairment in social, occupational, or other important areas of functioning”. Critics became concerned that, say, paedophilia could not be diagnosed in those who were quite happy with their desires and behaviour. In response, the diagnostic criteria were changed, and in DSM-IV-TR many paraphilias could be diagnosed so long as someone had “acted on these urges or is markedly distressed by them”. The unintended consequence is that under DSM-IV-TR those who commit sex crimes may meet the diagnostic criteria for a paraphilia by virtue of their crime alone. This goes against traditional psychiatric thinking (and the intentions of the DSM committees) which holds that the majority of sex offenders do not suffer from a mental disorder but are simply criminals. In the context of the US legal system the mistake takes on added significance, as the sexually violent predator laws in many states mean that offenders with a paraphilia diagnosis can be detained indefinitely. On reflection, Frances believes the problems stem from the fact that the diagnostic criteria in DSM-IV-TR contain an “or” instead of an “and”. If diagnosis with a paraphilia had required “fantasies, urges, and behaviours” rather than “fantasies, urges, or behaviours” then many fewer people would be diagnosable.

The DSM-5 may well also contain mistakes that will lead to the incidence of diagnoses changing in unexpected ways, though it is in the nature of such errors that they tend to become obvious only after a new edition has been in use for some years. One change in the DSM-5 that may have unintended consequences has occurred in the criteria for phobias. Previously patients had to recognise their fears as unreasonable, but now the fear merely has to be judged by the clinician to be out of proportion. This change has been introduced as many older adults who develop intense fears, say of falling, perceive their fears to be reasonable (LeBeau et al., 2010). However, potentially, this change has the consequence that those who develop rational fears on the basis of information that the diagnosing clinician lacks may be diagnosed. Suppose, for example, that I have unusual expertise: I study data about air traffic control systems. Based on my work, I come to believe the system is near collapse. I develop rational fears about plane crashes. Under the DSM-IV I did not have a phobia, as I would not have considered my fears unreasonable, but under DSM-5, if my clinician (who we will suppose knows nothing of these matters) judges my fear as being out of proportion, I can receive a diagnosis.

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