Psychiatric evolution

DSM-5 changes draw mixed reactions

Former President Bill Clinton may be the headliner at the May 18-22 American Psychiatric Association convention in San Francisco, but the release of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, known as DSM-5, will steal the show.

The manual offers a mix of sweeping and subtle changes that will have a major impact on the practice of psychiatry and the treatment of mental and behavioral problems for years to come. Though the writing process has been dogged by controversy because of the financial ties that many of its authors have with the pharmaceutical industry and by criticism that it seeks to turn routine life events into medically treatable episodes, this latest edition has mostly been greeted as having enormous benefit for the profession and for people with mental disorders.

One of its major shifts involves moving psychiatry further in the direction of the hard sciences as disorders become increasingly viewed as malfunctions in the biochemical processes of the brain. Dr. Jerry Halverson, president of the Wisconsin Psychiatric Association and medical director for adult services at Rogers Memorial Hospital in Oconomowoc, Wis., said the revisions take into account “an explosion of understanding” into the biology of some disorders.

This should offer more objective criteria so that patients don’t receive “three different diagnoses from three different doctors and get three different courses of treatment,” he said. The evolution in understanding some of the biological underpinnings of mental disorders may also help primary-care physicians by providing tools for assessing the mental health needs of their patients.

The major changes in DSM-5 span most of the controversial topics in contemporary psychiatry. They include changing the diagnosis and treatment of depression during periods of bereavement or grief; combining old categories of substance abuse into one category and linking pathological gambling with substance- abuse disorders; adding “binge eating disorder” to the categories of feeding disorders; looking more closely at the behavioral symptoms of post-traumatic stress disorder; and removing Asperger’s syndrome as a separate diagnosis (defined by MayoClinic.com as a “developmental disorder that affects a person’s ability to socialize and communicate effectively with others”) and including its symptoms as part of the broader autism spectrum disorder.

While criticism of changes to the DSM are expected—psychiatry is a highly contentious field whose practices have taken dramatic twists and turns over the decades—this edition has drawn fire from an unlikely source. Dr. Allen Frances, chairman of the task force of DSM-IV, the previous edition of the manual, said DSM-5 will do nothing to solve current problems involving too many people not getting the treatment they need while others are being prescribed drugs they shouldn’t take.

“The biggest misrepresentation is that it’s an official system, but no one needs to use it,” said Frances, a former chairman of the Duke University School of Medicine’s psychiatry department and currently professor emeritus. “I’m advising people not to buy it, not to teach it and not to use it.”

Francis is the author of the book Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life. “We can’t just ignore DSM-5 and be happy,” he said. “We have to look at the existing picture and problems of quick-draw diagnosis and over-medication.”

Those on the front lines of paying for psychiatric disorders so far appear sanguine about the changes, which they feel won’t have a major impact on the numbers of people seeking treatment, even if it does affect the nature of the treatments being offered. Dr. Mark Friedlander, chief medical officer for behavioral health at the insurer Aetna, said his company and the rest of the payer community support evidence-based criteria and feel DSM-5 will make no difference to their operations.

“Services are generally consumed based on clinical need, so whether a person can have a diagnosis that falls into this category or that is not as important as evaluating any functional impairment a person may have,” Friedlander said. “We’re looking at symptom severity, not specific diagnostic categories.”

The DSM-5 panel came under fire last year in PLoS Medicine, an online journal, when researchers from Harvard and Tufts universities criticized the “pernicious problem” of the DSM-5 task force members’ financial associations with the pharmaceutical industry. The authors wrote that the panel’s disclosure policy had not been accompanied by a reduction in financial conflicts of interest. “Transparency alone cannot mitigate the potential for bias and is an insufficient solution for protecting the integrity of the revision process,” they wrote.

Dr. David Kupfer, chairman of the DSM-5 task force, said in an e-mail that the panel’s standards were more stringent than similar panels at the National Institutes of Health or the Food & Drug Administration. “In 2012, 72% of the 153 members of the DSM-5 Task Force and Work Groups reported no relationships with the pharmaceutical industry during the previous year,” Kupfer said.

Even the critics downplayed the drug industry’s role in setting the new diagnostic criteria. The new manual may be “exploited by pharma,” said Duke’s Francis, but any potential areas of exploitation were not “instigated” by drug companies. “I think the pharmaceutical industry had no influence on this. These are very bad decisions made with clean intentions.”

Psychiatrists, like other physicians, don’t necessarily follow their professional societies’ guidelines. But the DSM-5 is more likely than most to diffuse quickly through to clinical practice. “It’s obviously going to be a big change,” said Halverson, who took part in field testing some of the manual’s symptom scales.

One of the major outstanding controversies involves the changes in diagnoses of depression and grief. Halverson said the intent was not to “pathologize being sad after a loss,” but to recognize that grief can trigger depressive symptoms—including what the APA describes as corrosive feelings of worthlessness and self-loathing—especially in patients who experienced these symptoms before. The intent, he said, is to get people the treatment they need when needed, “instead of suffering for a couple of months.”

Frances disagreed. He noted that DSM-IV called for treating people who were suicidal or delusional and couldn’t function. But it otherwise called for “watchful waiting.” Most people can get better without medication or a diagnosis, he said.