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No One Is Abandoning the DSM, but It Is Almost Time to Transform It


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(Credit: Ferris Jabr)

This month the American Psychiatric Association will publish the latest edition of its standard guidebook for clinicians, the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). In somewhat the same way that a field guide to birds helps people distinguish different species with illustrations and descriptions of physical features—a beak’s hooked tip, a blush of red plumage—the DSM helps clinicians recognize different mental illnesses with lists of typical symptoms, such as insomnia, low mood and hallucinations. The difference is that, whereas generations of biologists and birders have confirmed the existence of the animals they study—taking their pictures, holding them in their hands, comparing their DNA letter by letter—no one knows whether the disorders in the DSM are real.

Let me be clear: mental illness is real, but the discrete categories of illness in the DSM might not exist outside its pages. Are some people tired and miserable most of the time, plagued by spiraling thoughts of hopelessness and helplessness, unable to sleep—or sleeping too much—and uninterested in almost everything that once gave them pleasure, including sex? Absolutely. Their illness is real. Do all such people have a single disease that the DSM names depression? Probably not. Depression as defined by the DSM is a way of thinking about such symptoms. The DSM is not a catalogue of well-understood diseases with known causes that clinicians can identify with reliable diagnostic tests. It’s a book of useful concepts about some of our most complex and perplexing illnesses. It’s what we have to work with.

The American Psychiatric Association (APA) knows this. So does every major mental health organization, including the National Institute of Mental Health (NIMH). Recently, New Scientist, MIT Technology Review, Mind Hacks, The Verge and others—including my colleague John Horgan—proclaimed that the NIMH has suddenly decided to abandon, ditch or otherwise reject the DSM. This is a misunderstanding. Saying that the NIMH is rejecting the DSM is nonsensical. The fact is that psychiatrists need a common language in which to talk about their patients and the DSM—along with the similarly categorical International Classification of Diseases (ICD)—is the best guidebook available. In many cases, insurance companies require official DSM diagnoses before they help cover the costs of therapy and medication; the courts consider DSM definitions when discussing someone’s mental state; and the government still depends on the DSM when deliberating eligibility for disability benefits. None of that has changed.

NIMH has, however, been working on an endeavor known as the Research Domain Criteria Project, or RDoC for short, which encourages psychologists, neuroscientists and other scientists to think outside the DSM box—to begin transitioning away from established DSM disorders and instead study fundamental biological and cognitive processes underlying mental illness. The important distinction here is between clinical practice and research. The NIMH is not in any way saying that clinicians should stop using the DSM, but it does think that the DSM has constrained research. For a long time, scientists studying mental illness have found it much easier to get grants if they investigate an official DSM disorder and recruit participants who meet all the criteria for that disorder, rather than studying symptoms or unusual behavior not already sanctioned by the DSM. NIMH wants to change that by funding studies that are not strictly bound by the DSM‘s definitions.

Given that DSM disorders are useful inventions that do not perfectly mirror the reality of mental illness—or, in some cases, do not reflect its reality at all—the idea is to use modern tools to identify specific changes in the brain’s structure and behavior that at least partially explain the various symptoms of different mental illnesses. As I wrote in the May issue of Scientific American, “Some scientists might explore how and why the neural circuits that detect threats and store fearful memories sometimes behave in unusual ways after traumatic events—the kinds of changes that are partially responsible for post-traumatic stress disorder. Others may investigate the neurobiology of hallucinations, disruptions in circadian rhythms, or precisely how drug addiction rewires the brain.” RDoC is not a brand new development—it began in 2009—and it will continue for at least another decade. In the long-term, RDoC will hopefully improve not only diagnosis of mental illness, but also its treatment, by providing new specific biological targets for medication.

As far as I can tell, the recent confusion in the media began as a misinterpretation of Thomas Insel‘s April 29th blog on the NIMH website. Insel, Director of NIMH, and his colleague Bruce Cuthbert, Director of the Division of Adult Translational Research, are leading RDoC. Nowhere in his blog does Insel say he is abandoning the DSM, but he does make it clear that “the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure,” that “patients with mental disorders deserve better” than the DSM and that “NIMH will be re-orienting its research away from DSM categories.” None of this is particularly shocking to professional psychiatrists or anyone even moderately acquainted with psychiatry. I think the leaders of the APA would agree with just about everything Insel wrote. In fact, the NIMH and APA plan to collaborate to transform psychiatric diagnosis. RDoC is meant to help rewrite the DSM, not abolish it.

I got in touch with both Insel and Cuthbert to further clarify the matter. “The sensationalist headlines out there are entirely misleading, and we will continue to support DSM-based research as we increase our portfolio of RDoC grants,” Cuthbert wrote in an e-mail. “RDoC is intended to inform future versions of the ICD and DSM; we have no intention of coming out with a competing system. The implication of this is that the fruits of RDoC are likely to be taken up into the ICD/DSM piecemeal rather than in one entire set, at such times as the evidence for various aspects becomes strong enough to warrant changes to the nosologies.”

Insel echoed these comments in a separate e-mail: “We cannot ‘ditch’ or ‘reject’ terms like schizophrenia or bipolar. We just need to view them as constructs, perhaps including many different disorders that require different treatments or obscuring disorders than cut across the current categories. A symptom-only system will not be sufficient for identifying brain disorders—whether the initial label is dementia or schizophrenia.”

When censure comes easily, it is dangerously seductive. People get something akin to schadenfruede out of condemning the DSM and all of modern psychiatry along with it. Super important government institution rejects psychiatry’s beloved Bible! Psychiatrists in crisis. Everything will change. It’s so easy to tweet and retweet hyperbolic claims—or post a link on Facebook—before really understanding the issues. Something big is happening. I must be a part of it. But such sensationalism obscures the truth. The DSM is severely flawed, but it has improved over time; so has psychiatry. “Schizophrenia remains an immensely useful construct–imperfect for sure, but very helpful in clinical communication and in guiding treatment,” writes Allen Frances, a professor emeritus at Duke University, North Carolina, the chairman of the DSM-IV task force and one of the DSM-5‘s most vociferous critics. “The DSM disorders are all fallible and subjective constructs, but most are useful as temporary way stations until we learn more and can develop better ones.”

In so many of the recent critical articles about the DSM-5, the ironic implication is that abandoning the DSM is the right thing to do—that it’s a drastic but necessary move in order to help people with mental illness. Really? Abruptly abandoning the DSM would not help anyone. Fortunately that’s not what is happening.

About the Author: Ferris Jabr is an associate editor focusing on neuroscience and psychology. Follow on Twitter @ferrisjabr.

The views expressed are those of the author and are not necessarily those of Scientific American.





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  1. 1. presto 4:07 pm 05/7/2013

    is an ice cream scoop the best tool to use for brain surgery ? Maybe not but its a tool , its the tool we have to use !

    Link to this
  2. 2. joya.hunter 4:32 pm 05/7/2013

    Can anyone say “spin”? A little surprised @ Mr Jabr. Language seemed pretty unambiguous to me.

    Link to this
  3. 3. jimmywat 4:41 pm 05/7/2013

    http://www.psychologytoday.com/blog/dsm5-in-distress/201212/dsm-5-is-guide-not-bible-ignore-its-ten-worst-changes
    The Board of Trustees of the American Psychiatric Association has given its final approval to a deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound….DSM 5 has neither been able to self correct nor willing to heed the advice of outsiders. It has instead created a mostly closed shop- circling the wagons and deaf to the repeated and widespread warnings that it would lead to massive misdiagnosis….The APA’s deep dependence on the publishing profits generated by the DSM 5 business enterprise creates a far less pure motivation. There is an inherent and influential conflict of interest between the DSM 5 public trust and DSM 5 as a best seller. When its deadlines were consistently missed due to poor planning and disorganized implementation, APA chose quietly to cancel the DSM 5 field testing step that was meant to provide it with a badly needed opportunity for quality control. The current draft has been approved and is now being rushed prematurely to press with incomplete field testing for one reason only- so that DSM 5 publishing profits can fill the big hole in APA’s projected budget and return dividends on the exorbitant cost of 25 million dollars that has been charged to DSM 5 preparation….
    DSM 5′s ten most potentially harmful changes:
    1) Disruptive Mood Dysregulation Disorder: DSM 5 will turn temper tantrums into a mental disorder
    2) Normal grief will become Major Depressive Disorder
    3) The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder,
    4) DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs.
    5) Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness called Binge Eating Disorder.
    6) The changes in the DSM 5 definition of Autism will result in lowered rates- 10% according to estimates by the DSM 5 work group, perhaps 50% according to outside research groups. This reduction can be seen as beneficial in the sense that the diagnosis of Autism will be more accurate and specific- but advocates understandably fear a disruption in needed school services. Here the DSM 5 problem is not so much a bad decision, but the misleading promises that it will have no impact on rates of disorder or of service delivery.
    7) First time substance abusers will be lumped in definitionally in with hard core addicts despite their very different treatment needs
    8) DSM 5 has created a slippery slope by introducing the concept of Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot. Watch out for careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets.
    9) DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life.
    10) DSM 5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.

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  4. 4. ronpies 8:35 pm 05/9/2013

    Thank you, Mr. Jabr, for injecting a note of reason and balance into this imbroglio. I sometimes think that “APA” has come to stand for “American Pinata Association”, for all the beatings the APA has taken over the DSM-5!

    You are right in suggesting that there is no inherent contradiction between the DSM-5 categories–imperfect though they are–and ultimately “mapping” some of these categories onto specific brain regions or neurocircuits. That we are not yet able to do so is no indictment of the DSM system, or of psychiatry as a profession; rather, it reflects the fact that psychiatry is still a “young” science, as well as a healing art; and that we have not yet been able to find validated biomarkers for most of our diagnoses. (Actually, we know a great deal more about the biology of schizophrenia, bipolar disorder, and several other DSM categories than the public–and even many psychiatrists–realizes).

    Biomarkers and endophenotypes reflect one type of “validity” in science–but not the only type. Discriminant validity and predictive validity are also recognized properties of diagnoses, and several DSM categories possess these (e.g., the basic DSM criteria for schizophrenia show reasonably good predictive validity–see Mason et al, Br J Psychiatry. 1997 Apr;170:321-7).

    My personal preference for everyday clinical diagnosis is, in fact, not the “categorical” approach used in DSM-IV and 5; but rather, a “prototype matching” method, similar to the way residents learn about diagnosis by observing many patients over time
    (see, e.g., Lilienfeld & Marino, Journal of Abnormal Psychology 1999, Vol. 108, No. 3, 400-411)

    I would retain categorical diagnostic criteria primarily for research purposes (e.g., for defining inclusion criteria). Nevertheless–and even with its many flaws–the DSM system is likely to rema

    Link to this
  5. 5. ronpies 8:39 pm 05/9/2013

    Thank you, Mr. Jabr, for injecting a note of reason and balance into this imbroglio. I sometimes think that “APA” has come to stand for “American Pinata Association”, for all the beatings the APA has taken over the DSM-5!

    You are right in suggesting that there is no inherent contradiction between the DSM-5 categories–imperfect though they are–and ultimately “mapping” some of these categories onto specific brain regions or neurocircuits. That we are not yet able to do so is no indictment of the DSM system, or of psychiatry as a profession; rather, it reflects the fact that psychiatry is still a “young” science, as well as a healing art; and that we have not yet been able to find validated biomarkers for most of our diagnoses. (Actually, we know a great deal more about the biology of schizophrenia, bipolar disorder, and several other DSM categories than the public–and even many psychiatrists–realizes).

    Biomarkers and endophenotypes reflect one type of “validity” in science–but not the only type. Discriminant validity and predictive validity are also recognized properties of diagnoses, and several DSM categories possess these (e.g., the basic DSM criteria for schizophrenia show reasonably good predictive validity–see Mason et al, Br J Psychiatry. 1997 Apr;170:321-7).

    My personal preference for everyday clinical diagnosis is, in fact, not the “categorical” approach used in DSM-IV and 5; but rather, a “prototype matching” method, similar to the way residents learn about diagnosis by observing many patients over time
    (see, e.g., Lilienfeld & Marino, Journal of Abnormal Psychology 1999, Vol. 108, No. 3, 400-411)

    I would retain categorical diagnostic criteria primarily for research purposes (e.g., for defining inclusion criteria). Nevertheless–and even with its many flaws–the DSM system is likely to remain the predominant way of classifying psychiatric disorders for the near- and medium term.

    What is missing from this entire debate is an understanding that clinical medicine in general–including family practice–often lacks recourse to specific, validated, diagnostic entities, in its approach to the care of patients. In an excellent article in Atrium (Winter, 2013), Kirsti Malterud MD, PhD, describes two contrasting diagnostic strategies in clinical medicine, based on the teachings of Dr. Henry Cohen.

    The first is termed “Platonic” medicine, since it
    “pursues the disease as an ontological entity… representing the actual pathology…” –much like Plato’s “ideal forms”. The second is termed “Hippocratic medicine”, which emphasizes the patient’s narrative account of suffering and incapacity, and the balance between destructive and adaptive bodily processes. Dr. Malterud is blunt. She states, “The Platonic idea of diagnosis as the core symbol of clinical knowledge is mistaken…a clear and clean linearity between clinical phenomena, the names we can give them, and a subsequent rational treatment is the atypical exception, rather than the norm, in clinical medicine.”

    In short, psychiatry operates with many of the same diagnostic uncertainties inherent in clinical medicine in other specialties. That the DSM system is not firmly anchored in clear-cut “biology” may be regrettable, but it is far from being unique to the field of psychiatry. As Dr. Malterud wisely observes,

    “The professional norm that objective signs are supposed to confirm subjective symptoms and thereby reveal monocausal disease processes falls apart in the sea of medical complexities encountered by the…physician.”

    Ronald Pies MD
    Professor of Psychiatry
    SUNY Upstate Medical University;
    Clinical Professor of Psychiatry,
    Tufts University School of Medicine

    Link to this
  6. 6. American Muse 4:35 am 05/11/2013

    The conceit and hubris of APA in authorizing DSM manuals is astonishing. Why do we need a special “American” diagnostic manual for psychiatry alone? Why not use the ICD manual (International Classification of Disease) for psychiatric disorders as well, like all other medical specialties do for their illnesses?

    Link to this
  7. 7. concialitory 4:05 pm 05/19/2013

    I support the statements of several of the previous commentators which include my good friend and mentor, Dr. Ronald Pies but, please, do not forget the children. Despite its many flaws, I endorse the usefulness of DSM as a facilitator of communication among mental health professionals around the world. In a simplistic view, I would say that it is better to have a difficult language, i.e. Chinese, than not having one at all.
    On the other hand, I have been a consistent critic of the American Psychiatric Association’s (APA) absence of interest in updating diagnoses that made sense in the 80s and before, when the psychoanalytic establishment ruled that “children lack enough ego development to experience depression.” When the DSM-III was created, diagnoses such as Oppositional-Defiant Disorder (ODD), Disruptive Disorder NOS and Conduct Disorder (CD) were incorporated as a way of explaining behaviors (rapid mood changes, explosive anger, elevated mood expressed as defiance, etc.) because psychiatrists were not allowed to give “adult” labels to children. (1,2,3)
    For some reason that I can’t understand, psychoanalysts from previous centuries decided that children were shielded from mental illness while nothing could save them from receiving a life-threatening disease such as a brain tumor or leukemia. Many years later those that can change such a misconception have done nothing to correct it.
    When the APA made available the first DSM5-related website I immediately posted a request to take a look at the validity of ODD and CD. My impression that keeping alive those pseudo diagnoses was a danger to children that were missing treatment for their real conditions and helping the insurance companies to deny needed hospitalizations because, for example, a manic and suicidal adolescent also carries the Dx of ODD or CD.
    Other voices like doctors Charlie Huffine and Andy Pumariega have tried to get the APA’s attention to this issue but not to avail. On a daily basis, I see children of parents with serious mental illness misdiagnosed as having a combination of Attention-Deficit Hyperactivity Disorder (ADHD) and ODD that get worse with medications like amphetamines while the APA and the American Academic of Child and Adolescent Psychiatry behave as if this serious issue is not part of their responsibilities. When a person with an elevated mood, social anxiety, panic attacks, obsessive thoughts and compulsions, to mention just a few situations, is given methamphetamine or methylphenidate (the famous Ritalin) his or her symptoms increase, the blame goes to the patient “because he or she is not improving despite adequate treatment” and such refusal to improve “most be because of ODD.”
    Furthermore, the APA has never investigated why is it that 99% of the patients of a given doctor have the same diagnosis: ADHD. I am not talking of the case of a diabetologist (that only treats diabetics) or a neurologist that specializes in migraine, but of a general psychiatrist that evaluated children that come in search of a diagnosis.(4)
    For that the APA and I are at war and this conflict will last until its leaders assume the responsible obligation they have with millions of children on this planet.

    Manuel Mota-Castillo, M.D.
    Assistant Clinical Professor at UCF and FSU
    http://www.psychiatricanswers.com

    References:
    1- Is It Really ODD?, Mota-Castillo, M., Psychiatric Times, Feb 2004.
    2- Childhood Conduct Disorder and Oppositional-Defiant Disorder Are Common Manifestation of Bipolar Disorder; “Pro and Con”, Mota-Castillo, M. and Steiner, H.,The Journal of Bipolar Disorders Reviews & Commentaries; Dec. 2004.
    3- Eliminate Conduct Disorder & ODD…This is the Right Time!; Mota-Castillo, M., Psychline, Nov. 2004.
    4- The Crisis of Overdiagnosed ADHD in Children, Mota-Castillo, M.; Psychiatric Times, July 2007.

    Link to this
  8. 8. Moulton 3:54 am 05/23/2013

    “Are some people tired and miserable most of the time, plagued by spiraling thoughts of hopelessness and helplessness.”

    Yesterday, I concluded a long conversation with such a person. The conversation did not have a happy ending.

    Notwithstanding the likelihood that my shreklisch dialogue partner would probably be classified as Axis II, it occurred to me that the deeper problem was the rather commonplace failure to solve one of life’s recurring intractable problems.

    It occurs to me that people maladapt in a number of distinct and recognizable patterns when confronting life’s large and little problems. Some people become distressed in an emotionally volatile manner; some become dismayed, dispirited, or depressed. Some turn to research, others to the healing power of the arts. And some, I reckon, turn to unhealthy addictive modes of escape from their insoluble and intractable problems.

    If I were to give an insoluble problem to a computer which lacked a functional algorithm or method for solving it, what would it do? Would it eventually determine that it lacks a viable method of solution? Or would it spin its wheels endlessly in a fruitless search?

    It occurs to me that DSM is more a catalog of failure modes, classifying how many different ways a person can go crazy trying to solve any number of life’s intractable problems: conflict, violence, oppression, injustice, corruption, poverty, ignorance, alienation, suffering, and terrorism.

    Wouldn’t it make a lot more sense if we put our crazy heads together to devise ethical best practices for jointly solving these crazy-making problems?

    Link to this

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