MONDAY, May 20 (HealthDay News) -- As the American Psychiatric
Association unveiled last week the latest edition of what is
considered the "bible" of modern psychiatry, the uproar over its
many changes continues.
"This is unprecedented, the amount of commentary and debate and criticism," said Dr. Jeffrey Lieberman, president-elect of the American Psychiatric Association (APA). "It's been an interesting phenomenon, but the evidence is what it is. You have to evaluate it and then make your own determination of how compelling it is, and what would be best clinical practice."
The APA believes that changes made in this fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders(DSM-5)
will allow for more precise diagnoses of mental illnesses in
patients, because this edition better characterizes and categorizes
But it has drawn fire from critics who are concerned that the
revised version will lead to the diagnosis of mental illness in
people who are simply being challenged by life.
More than 1,500 experts from 39 countries representing a wide
variety of medical fields contributed to the new DSM-5, which was
more than a decade in the making. Drafts of the manual were made
available online as part of three open-comment periods that drew
more than 13,000 responses.
One of the most notable naysayers has been Dr. Allen Frances,
chairman of the task force that created the DSM-4, the previous
version of the guide that has been in use since 1994.
In a commentary released the day of the DSM-5's release, Frances
wrote that this latest revision introduces "several high-prevalence
diagnoses at the fuzzy boundary with normality," and predicted that
the changes "will probably lead to substantial false-positive rates
and unnecessary treatment."
"In DSM-5, normal grief becomes a major depressive disorder, temper tantrums become disruptive mood dysregulation disorder, worrying about medical illness becomes somatic symptom disorder, gluttony becomes binge eating disorder and almost everyone will soon qualify for attention-deficit disorder," Frances said in an interview.
The main points of contention regarding the DSM-5 include:
The combination of a number of autism-related disorders into a
single category called autism spectrum disorder. Although some
clinicians believe that placing autism on a continuum from mild to
severe will allow for more accurate diagnoses, others are concerned
that high-functioning people with autism will find themselves
unable to receive services or treatment. This is particularly true
of people with Asperger's Syndrome, a diagnosis that has been
eliminated from the DSM-5, critics of the new version contend.
"We're concerned that people who have Asperger's -- who have high-functioning autism -- are going to be dismissed as just being different when the majority of adults with Asperger's will need people to assist them in parts of their lives," said Karen Rodman, president and founder of Families of Adults Affected With Asperger's Syndrome.
"We are very concerned that medicine is going to drop the ball again, and the children who need services won't get them," Rodman said. "Fortunately, clinicians and physicians and the public around the world are still going to refer to Asperger's as Asperger's. It's like saying people don't have a right arm anymore.
"Many people with Asperger's are [also] concerned there will be a stigma -- that everyone will be considered autistic -- and when people think of that they think of a child sitting in a corner and spinning," Rodman added.
Lieberman called the DSM-5 "a reflection of the state of our
scientific knowledge," and strongly disagreed with the notion that
over-diagnosis and overmedication will be the end result of the
manual's new standards.
"This doesn't reflect any expansion of the people who would be diagnosed. It just classifies them in a more concise and accurate way," he said. "The goal of the DSM is not to expand the number [of people] who receive diagnoses who don't warrant them. The reality is that there is tremendous under-treatment of people with real needs, and this new revision will help."
Reflecting on the strong reaction to the changes, Lieberman said
it may go hand-in-hand with the public's uneasiness with mental
"I think there's a strong stigma factor associated with mental illness," he said. "There are people who are either fearful of it or want to minimize its existence. That stigma has been historic, but it has been diminishing with greater education and research and better treatment."
For his part, Frances ascribes nothing but good intentions to
those who worked on the new DSM, but is concerned that their
efforts will lead to bad outcomes.
"The people who are suggesting these changes are experts in their field who are pure of heart, but they have made terrible decisions because they don't understand that new diagnoses that may work well for them can be an absolute disaster in everyday care, especially when drug companies get their hands on them," he said.
Frances has written a new book,
Saving Normal, in which he argues that mental illness is
over-diagnosed in America. He urged both parents and clinicians to
be skeptical when it comes to the DSM-5 and any diagnoses that
spring from it.
"My advice to physicians is to use the DSM-5 cautiously, if at all," Frances concluded in his commentary. "It is not an official manual; no one is compelled to use it unless they work in an institutional setting that requires it."
Fore more on the DSM-5, go to the
American Psychiatric Association.
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