DSM-5: NOT WITHOUT CONTROVERSY

1. American Psychiatric Association DSM-5:NOT WITHOUT CONTROVERSY Psychiatry’s Manual of Disorders and the Issues Surrounding Its Design and Use

2. Researched and Developed by Rhinehart Lintonen An Introduction to DSM-5,Its Development, Changes, and Controversies The presentation herein is the intellectual property of Rhinehart Lintonen and does not reflect the attitudes or positions of the American Psychiatric Association. This presentation was developed for the use of the membership of the Milwaukee Area Teachers of Psychology and their students. Any other use should request permission at lintonen@hotmail.com. The intent of this presentation is to delineate the development of the present DSM and to document changes from DSM-IV-TR. Critiques and controversies presented are those of the persons or groups cited.

3. A Short History of the DSMThe Diagnostic and Statistical Manual ofMental Disorders

4. DSM-5, issued on May 18, 2103, is the culmination of changes begun in 1999 and intended to replace DSM-IV-TR which was seen as needing revision due to scientific discoveries in brain biology and issues surrounding perceived needed changes in the diagnostic categories themselves. • The prior editions stem back to post-World War II when the Army and Veteran’s Administration were looking for a way to diagnose what psychiatrically affected returning troops. • Thus began DSM-I, published in 1952. • Other revisions include DSM-II (1968), DSM-III (1980), DSM-IIIR (1987), DSM IV (1994) and DSM-IV-TR (2000) Development of the DSMs

5. Along the way, revisions reflected current thinking and trends in psychiatry • DSM-1 was largely psychodynamic in nature, reflecting Freud’s impact on psychiatry • Disorders referred to as “reactions” under the influence of Adolf Meyer and also showed the psychoanalytic bent • Two groups of disorders based on causality • Those caused by or associated with brain tissue dysfunction • Those of “psychogenic” origin not clearly related to structural changes in the brain • DSM-II increases number of disorders to 182 • Drops use of “reactions” while still using Freudian terms such as “neurosis” and “psychosis” Development of the DSMs Illustrations: American Psychiatric Assoc.

6. DSM-III represented a major change in the construction of the manual with 265 categories of disorders • Gone was the prior emphasis on psychodynamic views • Now the emphasis was on empirically-obtained observations • Coincided with move in US away from psychoanalysis and with publics’ skepticism of psychiatry in general • DSM-IIIR influenced by Emil Kraepelin’s insistence on the roles of biology and genetics in disorders • Task Force Chair Dr. Robert Spitzer suggested there was a hierarchy of mental illness (Greenberg, 54) • Dr. Allen Frances accords him great respect, saying that “Without Robert Spitzer, psychiatry might have become increasingly irrelevant” and that “Spitzer had laid the foundations for the psychiatric research enterprise.” (Frances, 62-63) • High praise for the man who guided the DSMs into a new direction APA Development of the DSMs New York Times

7. DSM-IV was not much of a sea-change from DSM-III • The number of disorders were now over 300 • Allen Frances, MD chaired the task force and insisted that the manual was not to be taken as a “Bible” of mental illnesses • All changes had to be science-driven and evidence-based and needed to have checks and balances which would protect against bias and individual’s pet ideas (Frances, xiii) • One of his regrets is that “Even though we had been boringly modest in our goals, obsessively meticulous in our methods, and rigidly conservative in our product, we failed to predict or prevent three new false epidemics of mental disorder in children – autism, attention-deficit, and childhood bipolar disorder.” (Frances, xiv) American Psychiatric Assoc. Development of the DSMs Photo: healthcareblog.com

8. DSM-IV-TR (2000) was an update to DSM-IV, not in the categories of disorders but in two main areas: • Prevalence • Familial patterns • These were updated to reflect new scientific knowledge regarding genetics and other neuroscientific advances What you’ve been teaching from all this time! Get ready to change what you knew! Development of DSM-5 American Psychiatric Assoc.

9. Beginning in 1999, there were specific calls for changes to DSM-IV-TR including: •In two decades, much new info on disorders had emerged •Biological psychiatry and neuroscience were being embraced with great enthusiasm • Prominent neuroscientists like Eric Kandel were proclaiming that “all mental disorders involve disorders of brain function.” (Greenberg, 61) • New drugs seemed to ease burden of psychological disorders • Think serotonin imbalances being eased by SSRI antidepressants (which later proved to be a false hypothesis) • Genetics research had added new knowledge of the possible sources of disturbances • Need for a more defined nosology (classification system) • A hoped-for “paradigm shift” to recreate that nosology Development of DSM-5

10. New edition preceded by 13 scientific conferences and a number of white papers, monographs, and journal articles researching and evaluating new nosologies • APA set up the DSM-5 Task Force of 27 members in 2007 under Chairman David Kupfer, MD and Vice-Chairman Darrel Regier, MD • 160 researchers and clinicians formed the Work Groups and Study Groups to develop the new manual, revising or tweaking criteria from the DSM-IV-TR and deleting or adding diagnostic classifications American Psychiatric Assoc. www.psychiatry.pitt.edu How Was DSM-5 Created? Kupfer Regier

11. The new task force stated in its goals that • “The previous version of DSM was completed nearly two decades ago; since that time, there has been a wealth of new research and knowledge about mental disorders.” (APA) • Therefore, the APA set about to use this evidence to determine whether certain diagnoses (a very hotly debated term) should be removed or changed • Additionally, the APA felt that they needed to better define the disorders by symptoms and behaviors than DSM-IV did • This would allow for future revision processes to be more responsive through incremental updates (DSM-5.0, 5.1, etc.) as new scientific breakthroughs became available How Was DSM-5 Created?

12. Changes like this are costly • DSM-5 cost between $20-25 million to produce • However, the DSM is a cash cow for the APA! • It is the sole agency producing such a product except for the ICD-10 • The greatest percentage of the income of the APA comes from its publishing arm • Since it brings in so much income, the DSM is critically important to the APA • There are calls for a more open, diversified medical organization to be created to write a new manual with more inputs and better designed to help the practice of psychiatry rather than simply refine the nosology (also important) How Was DSM-5 Created?

13. The New DSM-5Change is Good(Maybe)

14. Illus.: gracebooks.org • The old structure is gone • No more Five Axes • These were seen as incompatible with ICD-10 and other medical diagnostic systems • Replaced with a 0 to 4 point severity ratings scale for each diagnosis • No more assessment of global relative functioning according to a scale (GARF) • The term “general medical condition” has been replaced with “another medical condition” • Asperger Syndrome is no longer a discrete classification • Now merged into Autism Spectrum Disorder • Subtypes for Schizophrenia are gone • This was done because of low reliability, poor validity, and because of limited diagnostic stability (APA) • NOS categories (not otherwise specified) are now “other specified disorder” and “unspecified disorder” Basic Changes

15. Structure of the Manual • Preface • DSM-5 Classification and Coding • Section I • Use of the Manual • Cautionary Statement for Forensic Use of DSM-5 • Section II • Disorders listed among 22 major categories Basic Changes

16. Gone is the category “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” • These are now found under other appropriate headings • Other changes pertinent to each category will be discussed in the following section “The New DSM-5: Disorders” For a complete discussion of in-depth changes in each diagnostic category, go to: http://www.ldaofky.org/changes-from-dsm-iv-tr--to-dsm-5%5B1%5D.pdf Basic Changes

17. The New DSM-5The Controversies

18. news.bbc.co.uk • The new DSM has been under fire almost from the beginning • Initial complaints involved failure to supply minutes of committee meetings and questions about transparency • As time progressed, the questions and criticisms grew • Two camps essentially: • The American Psychological Association with David Kupfer and Darrel Regier defending their work • Former DSM-III and DSM-IV task force leaders Robert Spitzer and Allen Frances • This brought about what became high drama never before seen at this level of medical/scientific process • The availability of the Internet allowed the criticism to reach unheard of numbers of therapists and professionals able to comment on the proceedings DSM Under Fire

19. The Spitzer/Francis camp charged: • The manual was being drawn up in secrecy • Transparency was not being allowed • The Task Force members had to sign confidentiality agreements which limited their open discussion about the proceedings • DSM not etiologically based and adding things which were not disorders • Continued emphasis on Asperger’s, ADHD, and Childhood Bipolar Disorder (what Frances called “false epidemics”) would lead to diagnostic inflation (Francis, 77-86) • DSM-5 was leading to the “medicalization of normalcy” (Frances and Widiger, 123) • Too many psychiatrists on the development committees had ties to Big Pharma and were thus in danger of being influenced in their decisions (Frances, 75) The Charges

20. The Spitzer/Francis camp charged: • Field Trials were improperly vetted and hastily drawn up and weren’t adequately presented for review • The trials failed spectacularly in some areas with very low kappa scores • On a 0 to 1 scale, depression had a low 0.28; Mixed Anxiety-Depressive Disorder at -0.004 (Freedman, et.al.) • The APA was in too much of a hurry to bring the manual to market • APA’s financial vesting in the book meant that the organization needed to bring it to market quickly to continue the flow of sales • Behind it all, Frances charged that there were a number of conceptual issues: • “an elusive definition of mental disorder, the limits of neuroscience, the limits of descriptive psychiatry, an unclear epistemology, the absence of a unified theoretical model, pragmatism, and fads.” (Frances and Widiger, 109-110) The Charges

21. Frances admits that “Psychiatric classification is necessarily a sloppy business.” (Frances and Widiger, 114) and that “the only way to define a mental disorder is ‘that which clinicians treat; researchers research; educators teach; and insurance companies pay for.’” (Frances, 18) • Frances warns that DSM-IV had some unintended consequences being heightened by DSM-5 (Frances and Widiger, 115) • Four fads creating diagnostic inflation • autism • attention deficit • childhood bipolar disorder • paraphilia not otherwise specified The Charges

22. Additional critiques from Frances and others • APA was trying to create a paradigm shift in psychiatric diagnosis which is, at present, unrealizable • New category of Mood Dysregulation Disorder will create a mental disorder out of temper tantrums • Normal grief is being medicalized • Everyday characteristics of old age will be misdiagnosed as cognitive disorders • ADHD will lead to more adults being diagnosed in a fit of diagnostic inflation • Excessive eating is now a disorder, not just plain gluttony • Problems in everyday living will be elevated to General Anxiety Disorder • Behavioral addictions can apply to anything one does often enough The Charges

23. And the list goes on • Just exactly what is a mental disorder, anyway? • Are they simply problems in living as Thomas Szasz claimed? • Will we stigmatize too many people? • Will all of this encourage Big Pharma to find a drug for everything? • Many psychiatric drugs don’t work nearly as well as patient think anyway • At least a number of proposed “disorders” didn’t make it • E,g., Hypersexual Disorder • How much sex is too much? • Is it possible to be mentally ill because of a desire for sex? The Charges

24. Is it all for naught? Does DSM-5 or any other manual have any redeeming value? • The APA said it “would work to overcome one of the clearest limitations of our current diagnostic criteria…the lack of quantitative measures.” (Greenberg, 175) • Frances counters that we “still do not have a single laboratory test in psychiatry.” (Frances, 10) • However, the APA did adhere to attempting to validate all disorders through empirical evidence from clinical practice and an exhaustive search of the literature • So, at the end of the day, even Spitzer and Frances admit that, while it isn’t a “bible,” the DSM is still the best thing we have to guide us until something better comes along Anything Positive in DSM-5?

25. DSM-5 has many supporters among clinicians and therapists • It is considered robust compared to the ICD-10 or any other attempt to create a different manual • Perhaps therapists are best reminded that it is just a guide, it needs to be used judiciously, and the most apt advice may be that of the British Psychological Society which admonishes therapists to treat the person first, not the disease Anything Positive in DSM-5?

26. Other methodologies are in the works • Creating categories of disorders based on brain biology and neuroscience • Diagnosing disorders based on measuring the psychological dimensions of personality • Using a system of “stepped diagnosis” (Frances, 222) • A form of watchful waiting emphasizing normalizing problems and using minimal interventions until arriving at a definitive diagnosis and treatment plan Other Methodologies

27. The National Institute of Mental Health (NIMH) has an initiative known as Research Domain Criteria (RDoC) • The system would assess • Negative Valence Systems • Threat, fear of loss, frustration • Positive Valence Systems • Motivation, learning, and habit • Cognitive Systems • Attention, perception, and Memory • Social Process Systems • facial expression identification, imitation, attachment/separation fear • Arousal/Regulatory Processes • Stress regulation • These would be analyzed in terms of genes, molecules, and cells (Greenburg, 339-342) Another Possible System

28. The New DSM-5Diagnostic CriteriaDisorders

29. Conditions which begin in early development and which cause significant functional impairment Neurodevelopmental Disorders

30. Mental Retardation now called “intellectual disability” • Language disorders/stuttering now called “communication disorders” • Subcategories • Intellectual Disabilities • Communication Disorders • Autism Spectrum Disorder • Attention-Deficit-Hyperactivity Disorder • Specific Learning Disorder • Motor Disorders • Tic Disorders Neurodevelopmental Disorders www.dsrf.com

31. A group of disorders which is characterized by major disturbances in such areas as thought, language, perceptions, emotion, and behavior and which make it difficult to separate reality from fantasy Schizophrenia Spectrum and Other Psychotic Disorders

32. All subtypes deleted • Former subtypes are now diagnostic symptoms • Paranoid, disorganized, etc. • Subcategories • Schizotypal (Personality) Disorder • Delusional Disorder • Brief Psychotic Disorder • Schizophreniform Disorder • Schizophrenia • Schizoaffective Disorder • Substance/Medication-Induced Psychotic Disorder • Psychotic Disorder Due to Another Medical Condition • Catatonia • Other Specified Schizophrenia Spectrum and Other Psychotic Disorder • Unspecified Schizophrenia Spectrum and Other Psychotic Disorder Schizophrenia Spectrum and Other Psychotic Disorders

33. Disorders which are marked by major mood changes, alternating from manic to depressive and which can exhibit psychotic experiences – the reason they are located between Schizophrenia and Depressive Disorders in DSM-5 Bipolar and Related Disorders

34. Separated from Mood Disorders (category no longer exists) • A new specifier (“with mixed features” has been added for each subcategory • Anxiety symptoms are a specifier, although not part of the diagnostic criteria (in many of the categories such specifiers may now exist without being a diagnostic necessity) • Subcategories • Bipolar I Disorder • Bipolar II Disorder • Cyclothymic Disorder • Substance/Medication-Induced Bipolar and Related Disorder • Other Specified Bipolar and Related Disorder • Unspecified Bipolar and Related Disorder Bipolar and Related Disorders

35. Conditions in which the person feels in an extremely depressed mood for persistent periods of time, often without any letup or recurring in cycles Depressive Disorders

36. Replaces Mood Disorders Category for depressions • Specifiers have been added for mixed symptoms and also for anxiety • Most controversial: bereavement exclusion • Was excluded in DSM-IV-TR, now included • At what point should we medicalize normal grieving? • For children up to 18 a new category added • DMDD: Disruptive Mood Dysregulation Disorder • Also controversial • Now medicalizing temper tantrums? • Premenstrual Dysphoric Disorder now a subcategory • Subcategories • Disruptive Mood Dysregulation Disorder • Major Depressive Disorder • Persistent Depressive Disorder (Dysthymia) • Premenstrual Dysphoric Disorder • Substance/Medication-Induced Depressive Disorder • Depressive Disorder Due to Another Medical Condition • Other Specified Depressive Disorder • Unspecified Depressive Disorder www.healthclinicsource.com Depressive Disorders

37. Disorders which are marked by extreme conditions of fear or uneasiness that impair one’s basic functioning and which may or may not appear to have a cause according to the sufferer Anxiety Disorders

38. Panic Attack has become a specifier for all DSM-5 disorders • Panic Attack and Agoraphobia are no longer necessarily associated • Specific types of Phobia have become specifiers • No longer requires patient/client to recognize that their fear(s) are excessive or unreasonable • Duration now must be 6 months • Separation Anxiety Disorder and Selective Mutism have been moved here from Early Onset Disorders • Subcategories • Separation Anxiety Disorder • Selective Mutism Disorder • Specific Phobia • Social Anxiety Disorder (formerly Social Phobia) • Panic Disorder • Agoraphobia • Generalized Anxiety Disorder • Substance/Medication-Induced Anxiety Disorder • Anxiety Disorder Due to Another Medical Condition Anxiety Disorders

39. Subcategories(con’t.) • Other Specified Anxiety Disorder • Unspecified Anxiety Disorder Anxiety Disorders www.suzannesutton.com

40. Conditions which arise in response to some sort of traumatic event or severe stress; characteristic of not only soldiers, but many public safety workers and anyone, including children, who experience major shock Obsessive-Compulsive and Related Disorders

41. Four new disorders • Excoriation Disorder (skin-picking) • Hoarding Disorder (won’t the TV reality shows delight in this!) • Substance/Medication-Induced Obsessive-Compulsive and Related Disorder • Obsessive-Compulsive and Related Disorder Due to Another Medical Condition • Body Dysmorphic Disorder (BDD) adds criteria dealing with repetitive behaviors and mental acts “which may arise with perceived defects or flaws in physical appearance” (APA) • Specifiers have been added for “with good or fair insight,” “with poor insight,” or “with absent insight-delusional beliefs” • These also appear for Obsessive-Compulsive Disorder and Hoarding Disorder • Trichotillomania (hair-pulling) has moved here from Impulse-Control Disorders Obsessive-Compulsive and Related Disorders

42. Subcategories • Obsessive-Compulsive Disorder • Body Dysmorphic Disorder • Hoarding Disorder • Trichotillomania • Excoriation Disorder • Substance/Medication-Induced Obsessive-Compulsive and Related Disorder • Obsessive-Compulsive and Related Disorder Due to Another Medical Condition • Other Specified Obsessive-Compulsive and Related Disorder • Unspecified Obsessive-Compulsive and Related Disorder www.wedpages.scu.edu Obsessive-Compulsive and Related Disorders

43. Conditions in which the person experiences periods of obsessive thoughts often followed by compulsive behavior in response to that thinking; obsessions (thoughts) and compulsions (actions) can occur separately Trauma- and Stressor-Related Disorders

44. Now includes PTSD which was an anxiety disorder in DSM-IV-TR • Anxiety still an important symptom but not all sufferers will experience fear and anxiety • Symptom clusters now include negative alterations in cognition and mood • E.g., negative thoughts abut oneself, outbursts of anger, self-destructive behavior, etc. • Separate criteria for children 6 and under • Specifiers modified to some extent to reflect emotional reaction training of soldiers, police, emergency personnel • Two new disorders • Reactive Attachment Disorder • Disinhibited Social Engagement Disorder • Adjustment Disorders moved here as Stress-Response Syndromes Trauma -and Stressor-Related Disorders

45. Subcategories • Reactive Attachment Disorder • Disinhibited Social Engagement Disorder • Child approaching and interacting with strange adult • Posttraumatic Stress Disorder • Acute Stress Disorder • Adjustment Disorders • Other Specified Trauma –and Stressor-Related Disorder • Unspecified Trauma –and Stressor-Related Disorder www.knottiesniche.com Trauma -and Stressor-Related Disorders

46. Disruptions of cognitive functioning in which identity, consciousness, and memory can be impaired causing the person to experience confusion and discontinuity Dissociative Disorders

47. Dissociative Fugue no longer a separate condition • Now a specifier for Dissociative Amnesia • Depersonalization Disorder renamed Depersonalization/Derealization Disorder • Diagnosis for Dissociative Identity Disorder may include culturally-specific experiences of pathological possession • Also, identity transitions may be observed by others as well as self-reported • Now takes into account the nature and course of identity disruptions • Subcategories • Dissociative Identity Disorder • Dissociative Amnesia • Depersonalization/DerealizationDisorder • Other Specified Dissociative Disorder • Unspecified Dissociative Disorder Dissociative Disorders en.wikipedia.org Really?

48. Bodily symptoms (such as loss of function or pain) experienced as a result of extreme stress; formerly called “psychosomatic” symptoms Somatic Symptom and Related Disorders

49. Previously called Somatoform Disorders • Due to overlap and lack of clarity, these diagnoses have been eliminated • Somatization Disorder • Hypochondriasis • Considered a pejorative term • Pain Disorder • Some pain can be medical and there is a lack of validity and reliability in the distinctions • Undifferentiated Somatoform Disorder • Somatic Symptom Disorder is defined by positive symptoms • Psychological Factors Affecting Other Medical Conditions is a new disorder • Subcategories • Somatic Symptom Disorder • Illness Anxiety Disorder www.addictiontreatmenttherapy.com Somatic Symptom and Related Disorders

50. Subcategories (con’t.) • Conversion Disorder • Also known as Functional Neurological Symptom Disorder • Psychological Factors Affecting Other Medical Conditions • Factitious Disorder • Other Specified Somatic Symptom and Related Disorder • Unspecified Somatic Symptom and Related Disorder Somatic Symptom and Related Disorders