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The DSM Gets an Upgrade

The DSM Gets an Upgrade

On Tuesday, the American Psychiatric Association (APA) released its proposed revisions to the Diagnostic and Statistical Manual of Mental Disorders, sometimes referred to as the “bible of psychiatry.” If adopted, these revisions—which could affect whether people, including children, are prescribed psychotropic drugs for treatment, and whether insurance companies pay for their care—would be published in the fifth edition of the DSM, which will appear in 2013. Regarding the potential effect of these revisions, the February 10th New York Times quotes Dr. Michael First, a professor of psychiatry at Columbia University who edited the fourth edition of the DSM but is not involved in this current revision:

“Anything you put in that book, any little change you make, has huge implications not only for psychiatry but for pharmaceutical marketing, research, for the legal system, for who’s considered to be normal or not, for who’s considered disabled…..

“And it has huge implications for stigma…….because the more disorders you put in, the more people get labels, and the higher the risk that some get inappropriate treatment.”

Some disorders are being collapsed into others, and some new disorders are being added. While the intent is more accurate diagnosis, and therefore better treatment and understanding, of various conditions, the response (as seen in Dr. First’s comments) has ranged from perplexity to bafflement and even something more like outrage. Was the more up-to-date and best scientific evidence used? Did pharmaceutical companies or other financial interests have any influence? 

For instance, Asperger’s Syndrome, which was first recognized by the APA in 1994, is to be dropped under the new revisions and subsumed under the category of “autism spectrum disorder.” Anthropologist Roy Richard Grinker notes in a February 10th New York Times op-ed that, as more and more people were diagnosed with Asperger’s since its addition to the DSM in 1994, “public understanding of autism as a spectrum” was broadened”:

Almost everyone with Asperger’s also fits the profile of the more classic autistic disorder. Indeed, in the current diagnostic manual, a child who has good language acquisition and intelligence qualifies as autistic if, in addition to having restricted interests and problems with social interactions, he has just one of the following symptoms, which are common among children with Asperger’s: difficulty conversing, an inability to engage in make-believe play or repetitive or unusual use of language. Even the best available diagnostic instruments cannot clearly distinguish between Asperger’s and autistic disorder. 

People who now have a diagnosis of Asperger’s can be just as socially impaired as those with autism. So Asperger’s should not be a synonym for “high functioning.” Likewise, people with autism who are described as “low functioning,” including those without language, can have the kinds of intelligence and hidden abilities that are associated with Asperger’s — in art, music and engineering, for example — and can communicate if given assistance.

Collapsing “Asperger’s” into “autism” recognizes that terms such as “high-functioning” and “low-functioning” are relative; that just because an individual can (for instance) talk and has average or above-average intelligence, he or she may still face profound challenges in working, in daily living, and in many other areas. However, some believe that Asperger’s and autism should be separate conditions on the basis of “severity,” so it’s likely that debate (sometimes fierce) will condition about the existence of the “autism spectrum.” (Here are one mother’s views.)

The proposed DSM revisions also include the creation of some new disorders, such as “hypersexuality” for sex addiction; “binge eating disorder” as a “free-standing diagnosis” in the category of eating disorders; and temper dysregulation disorder with dysphoria (TDD). As the Child Psychology Research Blog notes, TDD would be given to children who have, it is now thought, been misdiagnosed with childhood bipolar disorder. Currently, children diagnosed with childhood bipolar disorder are treated with medications; treatment for children diagnosed with TDD would also include behavioral approaches. Indeed, “the standard treatment for bipolar disorder does NOT seem to work in children that have the TDD syndrome (Dickstein et al, 2009),” according to the Child Psychology Research Blog.

While the DSM is often spoken of in near-reverential terms (as, again, a “bible”), we have to remember that, once upon a time, there was no DSM (and, for that matter, once upon a time there were no such things as “psychiatry” or “psychology”). For instance, the first two editions of the DSM referenced autism under childhood schizophrenia; now people definitely shy away from any link of the two. (Professor Grinker’s 2007 book, Unstrange Minds: Remapping the World of Autism, also contains a history of the development of the DSM.) We’ve certainly learned much more about autism in the past decade, though much remains to discover, such as the causes of autism; a recent study suggests that both older mothers and older fathers can increase the “risk” of a child being on the autism spectrum. 

As we continue to examine and debate the proposed revisions to the DSM, we should perhaps try to see it not as an all-authoritative “bible” but as a document that is continually in need of revision, of questioning and of critique.

Read more:

Photo of DSM cover adapted from Unstrange.com.
Kristina Chew, Ph.D., is Associate Professor of Classics at Saint Peter's College in New Jersey. Since 2005, she has been blogging about autism, disabilities, and education, previously at Autism Vox and now at We Go With Him, a daily journal about life with her 12 1/2 year old son Charlie. Her essay, "The Wages of Autism," will be published in Gravity Pulls You In: Perspectives on Parenting Children on the Autism Spectrum, ed. Kyra Anderson & Vicki Forman (forthcoming, Woodbine Press). 

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42 comments

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12:54AM PST on Feb 16, 2010

Hi there,

I'm new to this forum and to be quite honest I dont know if I'm going to get sucked into it as I am finding with Facebook I am inundated with info and requests for help etc.

Anyway I am from the UK and perhaps our Health Service is different there but our GP's (General Practitioner) is allowed to prescribe anti-depressants and tranquillisers...no need to see a psychiatrist. Hence in the 1970's we had the "Valium Housewives" - apparently in the 1980's the divorce rate shot up when women's doctors began weaning them off their "Little helpers" My concern is that doctor's do push drugs..are they not financially rewarded to do so? Homeopathy does have its place in health and people have have quite clearly stated that it works for them. There was a comment that Sandra made about the 'Classroom Avengers' all being on prescribed drugs....why were these youngsters on 'Prescribed drugs' in the first place? Could it be that they were on the receiving end of bullying and harrassment, victimisation and humiliation? - issues that are not to be treated with drugs but by analysing your culture and how it creates the perfect environment for anguished and alienated kids to reach the end of their tether. It is a problem in any part of the world but I think possibly in the US where competition, winning and fitting in with ideals is to be strived for, you are punishing your children who cannot or do not want to do so. You have even given them names "Nerds" - perhaps Aspies?

8:10AM PST on Feb 15, 2010

I don;t know much about big pharma psyche drugs, except the extreme level of negative side effects that come from them, which can be found here
http://www.prozactruth.com/ with a lot of research about their negative consequences from taking them.

I also know there are a wide range of holistic remedies for different psychological problems that have been used fro thousand of years before big pharma, like ginseng for example.There are also, forms of meditation established a long time ago to help with psychological problems.

7:55AM PST on Feb 15, 2010

Check out this article too about the school shooter in Illinois. What they are not telling us is that all the school shooters so far had used some kind of anti-depressant.

This is very scary!


http://psychdrugs.wordpress.com/2008/07/29/antidepressants-violence-and-school-shootings/

7:20AM PST on Feb 15, 2010

Thanks again, Shevlin--your clarification was much appreciated!

4:26AM PST on Feb 15, 2010

Oh Sandra, do you mean me, that I have no idea what homeopathy is and commenting on it? WRONG. Except I obviously was wrong about blood tests and x-rays. Your statement is a generality.

I have run recently into a couple of fanatics who attack and vilify the entire 'medical establishment', a huge generality, even those who say like yourself "don't go to those people!"

And if you think I'm part of the 'medical establishment' in any way, shape or form you're WRONG again.

But I don't want to get sidetracked from this topic of Psychiatry or the DSM onto some big generality called the 'medical establishment'.


10:26PM PST on Feb 14, 2010

i have depressions, tried two different medications, one left me like a zombie and the other made me feel suizidal. so i went to a therapist and a homoepath, got two dogs and am feeling a whole lot better.

4:39PM PST on Feb 14, 2010

good post

2:22PM PST on Feb 14, 2010

Thanks Shevlin--you are so right. I think the mainstream doctors should just stay in the accident and trauma sector--they do very well there. They just don't have a clue about what keeps people healthy, and it is certainly NOT drugs.

Thanks for standing up for homeopaths. We have people on here who have no idea what homeopathy even is commenting on it. If you don't know what something is, you should stick with what you do know.

Thanks again, Shevlin!

As for psychiatry--I have to stick with Tom Cruise and his advice to Brook Shields a few years back on the Today Show when he took so much flack.

A scam, for sure and every single school shooter was on some kind of drug for mental illness.

12:51PM PST on Feb 14, 2010

Kenneth, homeopathic practitioners *can* take x-rays and order blood tests. If they have the proper training and certification in phlebotomy, they can draw the blood, too. The blood is sent to the same labs the medical community uses. A competent homeopathic practitioner can interpret test results just as well as a competent medical doctor.

I agree that there is a need for medical doctors. There is a need for both mainstream medical and the so-called "alternative" practices. They all have beneficial offerings when used appropriately. Mainstream western medicine is very good a treating trauma. The "alternatives" are very good at preventing disease and maintaining health, as well as curing some ailments. No homeopath will reattach a severed limb, but loading your body with chemicals to prevent or cure disease is ridiculous, especially if the "disease" is that you act outside the defined norm.

8:35AM PST on Feb 14, 2010

Sorry about the duplication, each one took about ten minutes to load onto here which screwed things up.

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