SAN FRANCISCO -- The fifth edition of the "psychiatrist's bible" was officially released here in all its 947-page glory, with its developers offering a spirited rebuttal to their critics.
Known as DSM-5, the new version of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders was launched at a press briefing to kick off the organization's annual meeting. Most of the changes from the previous edition had already been made public, at least in general outline.
At the briefing, DSM-5 Task Force chairman David Kupfer, MD, of the University of Pittsburgh, defended several of the most heavily criticized revisions from DSM-IV, as the last edition was called.
Other top APA leaders, including current president Dilip Jeste, MD, of the University of California San Diego, and president-elect Jeffrey Lieberman, MD, of Columbia University in New York City, addressed another, more recent controversy over DSM-5, which was sparked by a blog post from National Institute of Mental Health (NIMH) Director Thomas Insel, MD.
In his blog, Insel criticized the DSM classification system's scientific validity, and his remarks were then reported in consumer media as suggesting DSM-5 is "out of touch with science," as a New York Times headline put it.
Kupfer identified several specific changes from DSM-IV in the new edition that had drawn the most heat from others in the mental health community and patient advocacy groups.
Autism Spectrum
Whereas DSM-IV had four separate disorders that could be used for children showing symptoms associated with autism, these are collapsed into a single "autism spectrum disorder" with specifiers for specific symptom types and severities. Autism advocacy groups expressed concern that the revision would end up revoking some children's current diagnoses, depriving them of access to services.
Kupfer said the DSM-IV system had proved to be deeply flawed. The criteria for each of the four disorders were vague enough that diagnoses were inconsistent -- children with similar symptom constellations were being assigned to different DSM-IV classifications almost at random.
He said the task force was sensitive to worries about the consequences of revising the system, but they appear to be groundless. "We now already have findings and published studies that suggest that there will really be very little impact on prevalence or eligibility for services."
Bereavement Exclusion in Major Depression
As had previously been announced, DSM-5 drops the so-called "bereavement exclusion" from the diagnosis of major depressive disorder, under which the diagnosis was forbidden in individuals suffering a recent death of a loved one. Critics charged that the change would prompt many people experiencing "normal grief" to be labeled as depressed and given antidepressants, to the benefit of drug companies.
Kupfer said the criticism had arisen from "a misperception of what we were seeking to do and have done." He noted that patients in the grieving process are not immune from genuine, unhealthy depression. The task force's goal in dropping the exclusion was to "prevent major depression from being overlooked in some individuals who may be undergoing some form of grief or bereavement."
An APA fact sheet distributed at the briefing pointed to several features that "usually" distinguish depressive illness from normal grief in patients experiencing recent losses. They include continuous unrelieved negative mood and feelings of worthlessness and self-loathing. In normal grief, extreme sadness is typically intermittent and self-esteem is unaffected, the fact sheet said.
Disruptive Mood Dysregulation Disorder (DMDD)
One of the few entirely new conditions added in DSM-5, DMDD is for children 6 and older showing repeated and severe rage outbursts amidst long periods of chronic irritability and anger. Critics said this would open the door to diagnosis and treatment of temper tantrums within the spectrum of normal childhood behavior.
Kupfer said that was not the case. Worried parents have already been bringing children with these symptoms to pediatricians and child psychiatrists. Without a more specific diagnosis, many of these children end up diagnosed with bipolar disorder and treated accordingly.
"We're not referring to the usual childhood temper tantrum," he said. The diagnosis requires three or more rage outbursts per week for at least a year, and the under-6 age group that is most subject to tantrums is excluded from DMDD.
The diagnosis "is intended, in part, to address issues about potential overdiagnosis and overtreatment of bipolar disorder," Kupfer said.
Mild Neurocognitive Disorder
In a critique of DSM-5 published on the eve of its launch, the head of DSM-IV's development in the 1980s, Allen Frances, MD, of Duke University in Durham, N.C, singled out the new edition's inclusion of mild neurocognitive disorder as another example of medicalizing normal function. The "forgetfulness of aging," he suggested, is not something that needs diagnosis or treatment.
"There has been concern that we may have added a disorder that may not be important enough" to merit clinical attention, Kupfer said.
But as with the distinction between normal grief and diagnosable depression, he said the criteria specified in DSM-5 for mild neurocognitive disorder identify features that are clearly unhealthy and deserve recognition.
These include loss of functional abilities and the need for patients and caregivers to take steps to preserve independence.
"Clinicians have lacked a reliable diagnosis to assess such [impairments] and to understand what might be the most appropriate treatment or services," Kupfer said.
Including mild neurocognitive disorders in DSM-5 "serves two essential needs," he said. One is that it provides "an opportunity for early detection," while another is that it "encourages the development of an effective treatment plan before deficits become more pronounced and progress to dementia."
Insel's Comments
Apparently without meaning to, Insel set off a firestorm with an April 29 "director's blog" post on the NIMH website, in which he lamented that the DSM -- not just the new edition but its predecessors as well -- is not grounded solidly in biology. Rather, he said, "the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever."
As a result, Insel wrote, the DSM's validity -- that is, correspondence between the diagnostic labels and underlying biological pathology -- is largely lacking. "Patients with mental disorders deserve better," he wrote, and urged researchers to avoid grounding their grant applications on DSM-based disease classifications.
His remarks were quickly interpreted as an attack on DSM-5, which both he and the APA then denied. A joint statement by Insel and Lieberman issued last week sought to clarify Insel's intention, which was to highlight the lack of scientific understanding of most mental disorders' biological basis and the need for more and better research.
The DSM, "along with the International Classification of Diseases (ICD) represents the best information currently available for clinical diagnosis of mental disorders. Patients, families, and insurers can be confident that effective treatments are available and that the DSM is the key resource for delivering the best available care," the statement assured.
At the press briefing here, APA officials reiterated that there is, in fact, no disagreement with Insel.
"We support what he's trying to do," said John Scully, MD, the APA's chief executive officer. "We want him to get biomarkers for us."
Added Lieberman, "He [Insel] was trying to exhort the biomedical research community to try to break new ground that will lead to more dynamic and fundamental changes in psychiatric diagnosis."
Yet, Kupfer suggested, the flaws in DSM-IV for daily clinical practice needed to be addressed in the short term, and an extension of the symptom-based approach remained the only alternative.
"While we don't yet have the biomarkers that we are hoping are on the edge of discovery, patients can't keep waiting, and we can't keep waiting," he said.
Other Criticisms
Darrel Regier, MD, MPH, the APA's research director and vice chair of the DSM-5 task force, refuted the criticism that the DSM promotes overtreatment. "The DSM is not a practice guideline," he said. The APA does produce such guidelines, but they are developed "in an entirely separate process."
Many of the problems that the DSM and the psychiatric profession are accused of creating actually result from political decisions and policies beyond the physicians' control, he added. He pointed to the de-institutionalization movement of the 1970s that resulted in a major increase in homelessness.
That was not the fault of psychiatrists, he argued because they correctly recognized that many institutionalized patients would do better in community-based treatment. Instead, there was a lack of government planning and resources to provide such treatment to former mental inpatients.
"That's a social policy issue that goes far beyond a diagnostic manual," Regier said.
At another point, Scully said that many of the criticisms directed at the DSM and APA ultimately arise from "the stigma of mental illness."
Kupfer, responding to a question about excessive reliance on drug therapies in psychiatry, said he expected that physicians would not look only to drugs in treating patients diagnosed with mental illnesses; many nonpharmacological interventions are available and are known to be effective, he said.
DSM-5's Availability
DSM-5 is now on sale for $199 in hardcover and $149 in paperback. The APA has never made the DSM freely available (it is an important source of revenue) and no change in that policy is planned.
Two companion publications are also available immediately: a concise desk reference and a "pocket guide" to conducting diagnostic interviews aligned with the new edition.
A digital version is promised within a few months through a secure website and also as mobile device applications. Revisions will be more frequent and most likely would be distributed only electronically, Kupfer said.
Also later this year, several other print companions to the DSM-5 will be launched. These include a "user-friendly guidebook," a self-exam on the DSM-5 content, a study guide, clinical case studies, and a handbook for differential diagnosis.