Sunday, April 21, 2013

A Child Psychiatrist's Thoughts on DSM-5: General Impressions

The soon-to-be-published 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has been notable for the amount of controversy it has generated, including pointed critiques from Allen Frances, chair of the DSM-IV committee, and Robert Spitzer, chair of the DSM-III committee. There has been widespread media coverage of the controversies involved, in outlets ranging from the New York Times to The Verge. I won't recap all of the areas of contention, but I think the most insightful take about why the chairs of both DSM-III & IV would speak out against DSM-5 is offered by Dr. Nardo at In short, the DSM-5 committee explicitly set out to change DSM from an "atheoretical" perspective to one in which there are clearly defined biological causes of psychiatric diagnoses, but couldn't quite get there, leaving us with somewhat of a mess.

My own view of the DSM has always been that it's a very imperfect system, a necessary evil given how little we know. It tries to turn a spectrum of human behaviors and suffering into discrete categories, and frequently fails at that given how many patients I see who meet criteria for either multiple disorders (when presenting with one acute episode) or no disorder at all. It is necessarily subjective given that these disorders must cause "clinically significant impairment in functioning."

With the DSM-5, I think the biggest drawback is that the different committees that wrote the new criteria are all made up of experts in those particular areas. I'm not as concerned about their financial conflicts of interests (69% have received pharma funding) as I am about their innate desire to capture every possible case so that no suffering goes untreated. This approach (especially when it's applied outside of more "biologically-based" conditions such as autism or schizophrenia) can't help but lead to over-diagnosis when the manual is applied to an entire population by clinicians from all types of backgrounds.

As someone who treats adults in addition to kids and teenagers, I'm mostly disappointed when it comes to the DSM-5's changes to conditions generally diagnosed in adolescence and beyond. They did not really alter Major Depressive Disorder, which is so heterogenous a category that I highly doubt my patients with MDD who quickly get better after a month have a condition similar to the ones who remain hopeless and suicidal despite months of meds and therapy. I guess it's a diagnostic juggernaut with too many publications written about it already that's just too big to fail, kind of like the DSM itself. The criteria for Generalized Anxiety Disorder, a catch-all diagnosis like MDD, have actually been loosened. I'm also disappointed that there was ultimately no overhaul of the personality disorders to make them more dimensional. Some psychiatrists have complained that the new system would have taken too much effort, but I would argue that a personality disorder is not something that should be diagnosed based on a checklist; a clinician should actually observe a patient carefully over time before reaching the conclusion that a personality disorder is present.

One thing I do like about the DSM-5 is the change in name of the manual from the old Roman numeral system (i.e. "DSM-V"). The intent is supposedly that this is version 5.0, and that we won't have to wait a decade or two before new advances lead to versions 5.1, 5.2, and so on. It might be more aspirational than anything else, but being an optimist, I'm hopeful that this means changes could be more quickly made in response to...well, reality.

When it comes to changes in the DSM-5 for child psychiatry, I feel mostly positive. In future posts, I will explain why, as I examine DSM-5 changes in key areas such as PTSD, autism, ADHD, and the ever-controversial DMDD.