DSM-5 Heads to the Finish Line


The long-awaited fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, better known as the DSM-5, is set to be published next May, but critics continue to warn that the current proposals could lead to widespread misdiagnosis and a potential increase in the use of drug therapies.

The new manual takes a "developmental approach" to diagnosis, emphasizing the full lifespan of the patient, said Dr. David J. Kupfer, chair of the DSM-5 Task Force and a professor of psychiatry at the University of Pittsburgh.

Courtesy American Psychiatric Association

Dr. David J. Kupfer

"That automatically invokes an earlier concern about diagnosis," he said. "It automatically invokes the issue of what are some of the risk factors."

It’s that push for the early identification of mental illness that has some clinicians concerned.

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Dr. Allen J. Frances, who chaired the DSM-IV task force and is a professor emeritus at Duke University, said several proposals in the draft DSM-5 would take the idea of early diagnosis too far, essentially pathologizing normal behavior. For instance, he said, the current draft would classify normal grief as major depressive disorder and elevate "temper tantrums" to the status of disruptive mood dysregulation disorder.

Diagnostic inflation and excessive use of psychotropic medications already are rampant, Dr. Frances said, and broadening the diagnostic criteria in the DSM will only worsen that trend.

The developers of the current manual are getting ahead of the science, he said. In order to move to a model of what Dr. Frances called "preventive psychiatry," there needs to be an accurate system for identification without a high percentage of false positives. The treatment options also need to be safe and effective. Those conditions haven’t been met for most of the proposals in the DSM-5, he said.

"There’s a desire to push the field ahead without having the foundation to do it," Dr. Frances said.

Dr. Allen Frances

Some of those same concerns were expressed in an online petition posted by the Society for Humanistic Psychology (Division 32 of the American Psychological Association). To date, the petition has garnered support from more than 50 mental health organizations and more than 13,000 individuals.

But Dr. Kupfer defended the approach of the DSM-5, noting that in his clinical experience when an appropriate diagnosis is made earlier, there is less medical and psychiatric comorbidity.

"At any point in the age span, if we can make an earlier diagnosis, we would be better off," Dr. Kupfer said.

He added that the developmental approach in the draft DSM-5 would not automatically lead to the increased use of medication. Dr. Kupfer said a lot of work on non–pharmacologic treatments for early intervention has been done and that clinicians might just need to focus more on those options.

One proposal in the DSM-5 draft that was especially controversial was the plan to create a new diagnosis of attenuated psychosis syndrome. To qualify for the new diagnosis, patients would need to have relatively intact reality testing but exhibit delusions/delusional ideas, or hallucinations, or disorganized speech at least once a week for the past month. The idea was to describe a condition with the recent onset of modest, psychotic-like symptoms and clinically relevant distress and disability.

But after field tests failed to garner enough cases to adequately test the reliability of the diagnosis, the DSM-5’s Psychotic Disorders Work Group opted to put the new diagnosis in Section III of the manual, an appendix that describes diagnoses in need of further research.

Donna Rockwell, Psy.D., a clinical psychologist and a member of the executive board of the Society for Humanistic Psychology, said the concern with the attenuated psychosis syndrome proposal was that it was so sweeping that it could attach an inaccurate diagnosis to teenagers who were simply "quirky" or who might actually have Asperger’s syndrome.

Although some critics of the plan were worried that the diagnosis would unnecessarily put more teens on antipsychotics, Dr. Rockwell said she was also concerned about the impact of the label itself. Once diagnosed with attenuated psychosis syndrome, the psychotic label would follow the patient through life, Dr. Rockwell said. The diagnosis could potentially become a self-fulfilling prophecy in which patients would start to act out the behaviors expected of them, she said.

"There’s great concern among the psychological community that this is psychiatric overkill," Dr. Rockwell said.


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