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.
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).