DSM Dilemma: Issue 3

DSM-5 includes a new diagnosis called disruptive mood dysregulation disorder (DMDD) as severe and recurrent temper outbursts (three or more times a week for more than 1 year) that are grossly out of proportion in intensity or duration in children up to the age of 18. The mood before and after the temper outbreaks is persistently negative (irritable, angry, or sad), which is observable by others, and the tantrums and negative mood are present in at least 2 settings. The aim of the DMDD is to prevent the overdiagnosis of bipolar disorder in children with frequent temper tantrums and irritability.

"Critics believe that addition of disruptive mood dysregulation disorder could increase the number of children diagnosed with mental illness and unnecessarily expose them to medications with potential long-term adverse effects."

Critics of this change believe that the addition of this disorder is like attempting to diagnose regular childhood behavior which includes tantrums and irritability. They worry that such a diagnosis could increase the number of children diagnosed with mental illness and subsequent exposure to psychotropic medications with potential long-term side effects. One of the important reasons for opposition is the lack of concrete research into the validity of DMDD as a viable diagnostic entity. Furthermore, findings from a recent study raise concerns about the diagnostic utility of DMDD in clinical population. The study found that DMDD could not be delimited from oppositional defiant disorder and conduct disorder, had limited diagnostic stability, and was not associated with current, future-onset, or parental history of mood or anxiety disorders.

"The elimination of bereavement wrongly presumes that nobody can become seriously depressed while also grieving"

Perhaps the most controversial change found in the DSM-5 is the elimination of bereavementexclusion criteria from major depressive disorder. Therefore, grief, a normal reaction to the loss of a significant person might be diagnosed as major depressive disorder. Critics have spoken out strongly against this contentious revision claiming that it pathologizes a normal human process, grief. Additionally, some of the prominent critics question the validity of research supporting removing the exclusion. The defenders of this change, on the other hand, argue that grief does not prevent the development of full-blown depression, and that grief predisposes to MDD. Further, an uncompromising exclusion of MDD for 2 months after the death of a loved one wrongly presumes that nobody can become seriously depressed while also grieving.

"People diagnosed with mild cognitive disorder may be anxious that they are now prone to develop dementia."

DSM-5 introduces a new category of mild neurocognitive disorder (MCD). MCD is defined as 'a level of cognitive decline that requires compensatory strategies' to help maintain independence and perform activities of daily living. The DSM-5 clarifies that the cognitive decline goes beyond that which is typically associated with ageing. However, the concept of mild cognitive disorder has been attacked. The introduction of this category also carries the risk of pathologizing normal processes. Critics believe it will be a big challenge to make a clear distinction between incipient dementia and the level of cognitive impairment that goes with ageing. The main criticism is that there is little in the way of effective treatment for MCD, but if people are diagnosed with the condition it may cause needless stress and anxiety. People diagnosed with MCD may worry that they will go on to develop dementia, when this may not be the case.

"Changes made in the criteria for diagnosis of ADHD and autism can lead to two false epidemics."

The DSM-5 will retain the exact DSM-IV wording of all 18 symptoms, but has made a few controversial changes: first, the required age of onset has been raised from 7 to 12; second, it allows the diagnosis based only on the presence of symptoms, not requiring impairment; third, it has reduced the number of symptoms required for adults by half; and last, it allows the diagnosis of ADD in the presence of autism. Critics of these suggested changes raise a concern about implications of these changes. They believe these changes will most likely increase the prevalence of ADHD, especially in adults and adolescents, but may be also in children and increase in resulting stimulus misuse for performance enhancement. Lastly, allowing simultaneous diagnosis of ADHD and autism might create the interaction of 2 false epidemics, and encourage increased stimulant use in an especially vulnerable population.

"DSM-5 has reduced symptomatic duration and the number of necessary criteria for the diagnosis of GAD."

The "diagnostic threshold" for GAD was lowered in the new version of the manual. In previous versions, GAD was defined as having any three of six symptoms (such as restlessness, a sense of dread, and feeling constantly on edge) for at least three months. DSM-5 has reduced symptomatic duration and the number of necessary criteria for the diagnosis of GAD. In DSM-5, the diagnosis has been revised to having just one to four symptoms for at least one month. Critics believe that this lowering of the threshold could lead to people with "everyday worries" as being misdiagnosed and needlessly treated. They suggest that although this will not necessarily lead to a better recognition of GAD and an improvement in the perception of its relevance and clinical utility, many currently subthreshold cases will qualify for this diagnosis. Further, it is believed that the proposed behavioral diagnostic criteria lack specificity for GAD, and it is not clear how these will be assessed. The probable inclusion of many "false-positives" will result in an artificial increase in the prevalence of GAD and will have further negative consequences.

"DSM-5 will convert the current diagnostic inflation into hyperinflation by converting millions of normal people into mental patients "- Allen Frances

Perhaps the most prominent critic is Professor Allen Frances, the chair of the taskforce for DSMIV-TR. Apart from writing several articles criticizing the DSM-5, he has also published a book called “Saving Normal: An Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life.” Frances cautions that the new edition of the "bible of psychiatry," the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5), will convert the current diagnostic inflation into hyperinflation by converting millions of normal people into mental patients. Frances argues that whenever one arbitrarily labels another aspect of the human condition a "disease" human adaptability and diversity is diminished further. The book is a call to reclaim the full measure of humanity.

Nick Craddock: He notes that the categories are based on lists of symptoms that don't necessarily chart well onto the underlying biological and psychological processes involved in emotion, behavior, and cognition. He claimed that more aspects of emotion, behavior, and cognition are going to be labeled as diagnoses. Citing an example of DSM-5's removal of the bereavement exclusion, he believes that the new DSM will medicalise more of what most people view as normal human behavior. He believes that just like a large proportion of psychiatrists in the UK and Europe, many other psychologists would also be as skeptical about the manual as he is.

Peter Kinderman: Professor of clinical psychology at the University of Liverpool: He believes that DSM-5 is making the process of describing and explaining situations worse. He notes that the proposed revision will include a vast number of social, psychological, and behavior problems in the category of mental disorder, so pathologising mild eccentricity, l loneliness, shyness, sadness, and much else. As a result, he is concerned about what this will mean for the person who receives the label. He is sensitized toward consequences of people who will be categorized as mentally ill. Professor Kinderman suggested that there is a genuine need to reconsider psychiatric diagnosis.

Largely, the impression is that the DSM-5 has lowered diagnostic thresholds in a good number of cases. This may lead to an increase in unnecessary treatment and a mislabelling of people. Some critics have gone ahead and said that it will be difficult to be normal after the publication of DSM-5. Thankfully, clinicians are in control of these diagnoses and can negotiate a fine line between under and over diagnosis. An inaccurate or missed diagnosis is damaging because it automatically restricts the repertoire of therapeutic interventions available to the individual or denies them treatment altogether. However, over diagnosis is equally unhelpful and potentially damaging, as it pathologises 'normal' behaviour and mandates treatment for those without an illness.