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APA Leaders Defend New Diagnostic Guide

  • - Dementia News
  • May 19, 2013
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Tags: | autism spectrum | autism spectrum disorder | dsm-5 | major depression |

The fifth edition of the “psychiatrist’s bible” was officially released here in all its 947-page glory, with its developers offering a spirited rebuttal to their critics.

Known as DSM-5, the new version of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders was launched at a press briefing to kick off the organization’s annual meeting. Most of the changes from the previous edition had already been made public, at least in general outline.

At the briefing, DSM-5 Task Force chairman David Kupfer, MD, of the University of Pittsburgh, defended several of the most heavily criticized revisions from DSM-IV, as the last edition was called.

Other top APA leaders, including current president Dilip Jeste, MD, of the University of California San Diego, and president-elect Jeffrey Lieberman, MD, of Columbia University in New York City, addressed another, more recent controversy over DSM-5, which was sparked by a blog post from National Institute of Mental Health (NIMH) Director Thomas Insel, MD.

In his blog, Insel criticized the DSM classification system’s scientific validity, and his remarks were then reported in consumer media as suggesting DSM-5 is “out of touch with science,” as a New York Times headline put it.

Kupfer identified several specific changes from DSM-IV in the new edition that had drawn the most heat from others in the mental health community and patient advocacy groups.

Autism Spectrum

Whereas DSM-IV had four separate disorders that could be used for children showing symptoms associated with autism, these are collapsed into a single “autism spectrum disorder” with specifiers for specific symptom types and severities. Autism advocacy groups expressed concern that the revision would end up revoking some children’s current diagnoses, depriving them of access to services.

Kupfer said the DSM-IV system had proved to be deeply flawed. The criteria for each of the four disorders were vague enough that diagnoses were inconsistent -  children with similar symptom constellations were being assigned to different DSM-IV classifications almost at random.

He said the task force was sensitive to worries about the consequences of revising the system, but they appear to be groundless. “We now already have findings and published studies that suggest that there will really be very little impact on prevalence or eligibility for services.”

Bereavement Exclusion in Major Depression

As had previously been announced, DSM-5 drops the so-called “bereavement exclusion” from the diagnosis of major depressive disorder, under which the diagnosis was forbidden in individuals suffering a recent death of a loved one. Critics charged that the change would prompt many people experiencing “normal grief” to be labeled as depressed and given antidepressants, to the benefit of drug companies.

Kupfer said the criticism had arisen from “a misperception of what we were seeking to do and have done.” He noted that patients in the grieving process are not immune from genuine, unhealthy depression. The task force’s goal in dropping the exclusion was to “prevent major depression from being overlooked in some individuals who may be undergoing some form of grief or bereavement.”

An APA fact sheet distributed at the briefing pointed to several features that “usually” distinguish depressive illness from normal grief in patients experiencing recent losses. They include continuous unrelieved negative mood and feelings of worthlessness and self-loathing. In normal grief, extreme sadness is typically intermittent and self-esteem is unaffected, the fact sheet said.

Disruptive Mood Dysregulation Disorder (DMDD)

One of the few entirely new conditions added in DSM-5, DMDD is for children 6 and older showing repeated and severe rage outbursts amidst long periods of chronic irritability and anger. Critics said this would open the door to diagnosis and treatment of temper tantrums within the spectrum of normal childhood behavior.

Kupfer said that was not the case. Worried parents have already been bringing children with these symptoms to pediatricians and child psychiatrists. Without a more specific diagnosis, many of these children end up diagnosed with bipolar disorder and treated accordingly.

“We’re not referring to the usual childhood temper tantrum,” he said. The diagnosis requires three or more rage outbursts per week for at least a year, and the under-6 age group that is most subject to tantrums is excluded from DMDD.

The diagnosis “is intended, in part, to address issues about potential overdiagnosis and overtreatment of bipolar disorder,” Kupfer said.

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