Oh, the outrage! Well, not really. It’s more like mass confusion. Several new diagnoses will appear in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-V). But, has the firestorm of criticism grounded the manual before it even takes off?
Even Dr. Allen Frances, psychiatry professor emeritus at Duke University, who chaired the DSM-IV task force, called the day on which the DSM-V was approved “a sad day for psychiatry.” Of greatest concern to many, is the new manual’s potential to over-pathologize human behavior, calling into question the validity of new diagnoses.
Disruptive Mood Dysregulation Disorder, for example, is intended to describe children between 6 – 18 years of age who show some signs of potential childhood-onset bipolar disorder. This new disorder’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. Good intentions likely steered DSM-V to create this classification in the hopes of deterring clinicians from prematurely diagnosing bipolar disorder, a serious mental illness with associated stigma, as well as medications that carry with them a host of potentially significant adverse effects.
Excoriation (Skin Picking) Disorder has been added to the 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 psychiatric diagnosis of many normal individuals with normal behaviors. But, as others have noted, skin picking is more than “just popping a few pimples and having a few scars.” Yes, everyone picks at his or her skin at some point; however, skin picking as a disorder, is intended to far exceed “normal” grooming behavior. Think of grooming behavior as occurring on a continuum, with normal, washing and exfoliating on one end of the continuum, extending to picking, scraping, or gouging that results in scarring or disfigurement on the other end. So, perhaps the poor DSM-V may be getting a bum rap for being misunderstood? Maybe. Maybe not.
So, what does this mean for the average person? It’s unclear. What this could mean is that children with temper tantrums (that would be most kids, right?) could potentially be thought of and evaluated and/or treated for a psychiatric illness. Tantrums may become more than tantrums, but rather potential symptoms of mental illness. That’s a pretty frightening prospect, as in most cases these children are not likely to go on to struggle with bipolar disorder. Or, it could mean that seemingly normal grooming behavior, such as skin picking, may become associated with mental illness, bringing legions of those struggling with acne to therapists’ offices.
We may be on the verge of a societal shift in what is viewed as normal behavior being over-pathologized. Or, perhaps these are mere over-reactions and these problems will only be seen as problems when manifested in their extremes. Only time will tell.
Is DSM-V truly the “be all and end all” tool for diagnosing mental health? Actually, no. Healthcare isn’t quite that simple. Some clinicians argue that there is little point in lashing out against the DSM-V, as may will have little relevance. Healthcare providers are tied to a different, essential manual for billing and coding purposes, the International Classification of Diseases, Ninth Edition (ICD-9). 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-V, there is likely to be confusion and billing issues. Incidentally, ICD-10 will not be released until 2014. So, some frustrated clinicians contemplate whether they will pay any attention to the DSM-V’s release, and, instead, continue to use the DSM-IV/ICD-9 coding system. This does raise an excellent point, but perhaps this is merely disgruntled resistance to change.
This recent revolt has perhaps culminated in the bold, yet, not unexpected, statement by Thomas Insel, MD, Director of the National Institute of Mental Health (NIMH). Dr. Insel’s “Director’s Blog” entry on April 29, 2013, expressed his displeasure with DSM’s symptom-based categorical approach as a whole. He noted that the longstanding 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 significant advancements in neuroscience, the DSM’s approach to diagnosis has become outdated, relying on clusters of observable symptoms, rather than measurable science.
Although Dr. Insel’s statement came as a surprise to some, the NIMH has been working to develop a set of criteria for the development of a new system for classifying mental illness for more than a year. It just so happens that this may be a convenient time to gain support and momentum for NIMH’s newly launched Research Design Criteria (RDoC) project, which has been in development for 1.5 years. 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.”
Ask clinicians when DSM-V is expected to be released or how long it was “in the works,” and they are likely to joke about the more than a decade painstaking wait for this lackluster manual. However, it’s difficult to even fathom the probable wait that the mental health field has to endure for the fruit of the RDoC’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 button to order my new DSM-V.
I’m blogging for mental health. Mental health month blog day.