Controversial DSM-5 Changes: Task Force Chair Addresses Critical Questions
On Dec. 1, 2012, the American Psychiatric Association (APA) announced that its Board of Trustees approved the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Some of the proposed changes in this revision — the first since 1994 — have generated heated controversy on the part of medical professionals, as well as patients and consumers. Below, David Kupfer, MD, Thomas Detre Professor of Psychiatry and professor of Neuroscience and Clinical and Translational Science at the University of Pittsburgh School of Medicine, and chair of the DSM-5 Task Force, offers insight into some of the most controversial issues.
These issues include:
- Removal of the "bereavement exclusion" in the major depression section — patients may be called clinically depressed sooner than two months, although the criteria will include advice to clinicians about distinguishing normal grief from depression that should be treated.
- Addition of "disruptive mood dysregulation disorder" diagnosis for children >6 years old who show frequent bursts of anger along with chronic irritability.
- Collapse a number of autism-related conditions treated as separate disorders in DSM-IV into a single "autism spectrum disorder" category
In general, what did the committee hope to achieve with the DSM-5 revisions?
The overarching goal of the DSM-5 revision has been to take into account the scientific and clinical advances that have been made over the past 20 years since the last revision. The aim has been to, wherever possible, make appropriate changes in criteria and establish new diagnoses that would make the DSM more useful to clinicians and the patients they serve.
Please comment on the removal of the "bereavement exclusion." What was the rationale for this, given that clinicians are going to be given specific advice about how to distinguish normal grief from depression?
As part of the ongoing study of major depression, the bereavement exclusion has been removed from DSM. This deletion from DSM-IV will be replaced by notes in the criteria and text that caution clinicians to differentiate between normal grieving associated with a significant loss and a diagnosis of a mental disorder. We reviewed the literature and had a number of advisors go over the available research to help inform this decision. We made this change because it is very important that clinicians have an opportunity to make sure that patients and their families receive the appropriate diagnosis and the correct intervention without necessarily being constrained by a period of time. In the same sense, it is important to realize that we have provided several notes in the manual to make sure that it is understood that sadness, grief, and bereavement are not things that have a time limitation to them. It is not something that goes away within two or three months. The changes encourage clinicians to assess clients on a case by case basis, without limiting them by an arbitrary period of time.
How does the addition of "disruptive mood dysregulation disorder" as a diagnosis affect the practical day-to-day treatment of children who fall under that diagnosis?
The hope is that by defining this condition more accurately, clinicians will be able to improve diagnosis and care of children with these behaviors. Defining this disorder as a distinct condition will likely have a considerable impact on clinical practice and thus treatment. For example, the medication and psychotherapy treatment recommended for bipolar disorder is entirely different from that of other disorders, such as depressive and anxiety disorders. By defining this condition more accurately, clinicians will be able to improve diagnosis and care.
How can you reassure those people with a current diagnosis of Asperger's, as well as parents and Asperger support groups, that the approved changes in diagnosis will not stigmatize them further and will not deprive them of services that go along with the Asperger classification (when they are too high-functioning to fit onto the "autistic spectrum")?
If someone has received a DSM-IV diagnosis of autistic disorder, Asperger's disorder, pervasive developmental disorder-not otherwise specified, or child disintegrative disorder, the current diagnosis is still valid, and the person should not be rediagnosed. If for some reason the person does need to be rediagnosed, research shows that nearly everyone who qualified for one of those four diagnoses in DSM-IV will also meet the criteria for autism spectrum disorder using DSM-5. DSM does not outline recommended treatment and services for mental disorders. The change in diagnostic terminology would not invalidate any treatment or services that have worked for someone diagnosed with Asperger's disorder.
How will the new trait-specific methodology for diagnosing the ten personality disorders improve diagnosis?
DSM-5 will maintain the categorical model and criteria for the ten personality disorders included in DSM-IV and will include the new trait-specific methodology in Section III of DSM-5 to encourage further study about how this could be used to diagnose personality disorders. The trait-specific methodology is not in the main section of DSM-5.