The American Psychiatric Association has just released draft revisions for the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for a two-month comment period. (The DSM-5 will be published in May 2013.) Because mental health professionals and healthcare payers rely on the DSM for diagnoses, changes to it can influence millions of people.
A few specific diagnoses – especially bipolar disorder in children and autism spectrum disorder – are getting a lot of the attention, but the draft revisions also include an important change in how diagnoses are made. A new “dimensional assessment approach” will take into account the severity of patients’ symptoms as well as the number of symptoms of particular disorders they exhibit. NPR’s Kathleen Masterson, citing an example from DSM task force member Dr. Darrel Reiger, explains:
Regier gives the example of depression. In diagnosing major depression — a well-documented and studied disorder — doctors use a checklist of nine symptoms. Patients who meet five out of nine criteria can be said to have major depression.
But what about a patient who only has four symptoms, yet all are very severe? Say this patient has thoughts of suicide, sleeping problems, trouble concentrating and a depressed mood so severe he can’t drag himself out of bed. Technically, the way the current DSM-IV is set up, this person would be considered free of major depression because he meets only four criteria.
Under the newly proposed system a patient wouldn’t need five criteria to be diagnosed with major depression. The severity of the symptoms a patient does have would be factored into the diagnosis.
To some degree, doctors are already assessing patients this way. “It’s not new in practice,” says Dr. David Shaffer, chief of the division of child and adolescent psychiatry at Columbia University Medical Center. Doctors treat patients who need help even if their symptoms don’t add up to a clear-cut disorder. And, he says, researchers and people testing treatments already use scales of severity to describe the patients in their studies. “So the goal is to somehow bring that into the diagnosis.”
In terms of specific diagnoses, the DSM’s task force proposes replacing the diagnosis of bipolar disorder in children with a new label, “Temper Dysregulation Disorder.” I knew that a recent spike in pediatric bipolar diagnoses and an accompanying surge of prescriptions for antipsychotic drugs (which have worrisome side effects) has caused some health professionals to sound alarms. What I was surprised to learn from a report by NPR’s Alix Spiegel, though, was that the diagnosis of bipolar disorder in children was first suggested by researcher Janet Wozniak (who’s now at Massachusetts General Hospital) in the mid-90s, but the folks at DSM had been skeptical of it. Here’s Spiegel talking with David Shaffer of Columbia University Medical Center, one of the members of the DSM task force:
SPIEGEL: Wozniak wrote up a paper which proposed that many of the kids diagnosed with ADHD were actually bipolar, and it was hugely influential. But David Shaffer and many other psychiatrists were never convinced. He says that in order to claim that these kids were bipolar, Wozniak had to change one critical component of the traditional definition of bipolar disorder, also known as manic depression.
Dr. SHAFFER: The defining feature of manic depression was that it was episodic, that you had episodes of depression and episodes of mania and episodes of normal mood.
SPIEGEL: But the kids Wozniak described rarely had discreet week-long or month-long episodes. They just had consistent problems with rage. The fact that the kids dont have episodes, Shaffer says, is one reason that people at the DSM were skeptical of the childhood bipolar label. And he also points out that bipolar disorder is supposed to be a lifelong condition, but the kids Wozniak identified don’t always grow up to have problems with their moods.
University of Washington psychiatrist Jack McClellan told the New York Times’ Benedict Carey that the change in diagnosis will likely mean that a behavioral rather than pharmaceutical treatment will be considered the primary treatment for children suffering from the disorder.
In yet another NPR story, Jon Hamilton highlights the proposed incorporation of Asperger’s syndrome into the broad diagnosis of “autism spectrum disorder.” Although many people understand Asperger’s as high-functioning autism, the current DSM separates the two diagnoses. Hamilton explains that many people diagnosed with Asperger’s don’t like the thought of being in the same category as people with severe forms of autism. The executive director of the Global and Regional Asperger Syndrome Partnership, John Carley, told Hamilton that he’ll find it hard to call himself autistic – but he agrees with the DSM task force’s decision.
The American Psychiatric Association states that it welcomes input from clinicians, researchers, administrators, and anyone who is “a person/family member affected by a mental disorder.” More details are available at the DSM-5 Development website.