By Ljudmila Petrovic
Photos by Vaikunthe Banerjee
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is considered the Bible of mental illness diagnosis. It is published by the American Psychiatric Association (APA) and is used by clinicians across North America. This week will see the release of the long-awaited fifth edition of the DSM.
Why should we care? Well, the fourth edition was first published in 1994, with a revised edition in 2000. Just to make the math as simple as possible, this means it’s been 13 years since the last manual came out. Needless to say, there has been an incredible amount of research done in various fields of psychology since then, and many of the proposed changes have been widely controversial.
While there are many structural and nit-picky changes that are essential for practitioners (such as a change in the order of disorders), there are also some changes that have huge social implications and will have a significant impact on the face of modern mental health and diagnosis.
Listed below are some of the major changes, and some of the controversies that accompany the release of this most recent fifth edition of the DSM.
Autism Spectrum Disorder and Asperger’s
Prior to the DSM fifth edition, Autism Spectrum Disorder (ASD) was listed as four separate disorders: autistic disorder, Asperger’s disorder (a milder version of social disability), childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. This change is meant to acknowledge that these individuals fall along a spectrum of varying severity. ASD is characterized by both: 1) deficits in social communication and social interaction, and 2) restricted repetitive behaviors, interests, and activities (RRBs).
While these changes are made based on extensive research and expertise, some groups have raised concerns about the implications of these changes. The Autism Research Institute (ARI) notes that some of the higher-functioning individuals might no longer meet the stricter diagnostic criteria, which would inhibit their access to supportive services. Furthermore, it is uncertain how services — including in schools — will accommodate these changes and the individuals that could be at risk of falling through the cracks.
Gender Identity Disorder
Individuals who do not identify with their biological gender were, until now, diagnosed with Gender Identity Disorder. The newest revision in this area is that these individuals will no longer be labeled as having a disorder; if they seek psychiatric treatment, they will be identified as having “gender dysphoria,” or an unhappiness with their biological gender. The idea behind this change is that there is less stigma attached to individuals if they are not deemed to have a “disorder.” On the other hand, if they have an identifiable mental health issue, they have better access to resources and therapy.
This change signifies a big step for the LGBTQ community, which has historically been stigmatized in the DSM; it was not until 1986 that homosexuality was removed entirely as a DSM disorder. Trish Garner, an instructor in the Gender, Sexuality and Women’s Studies department at SFU, argues that this situation is much more complex than the historic inclusion of homosexuality in the DSM.
“Homosexual bodies don’t need or want any medical attention, so there was all the activism around removing it,” she explains. “It was clear that we had to move away from the pathologization but in terms of transgendered patients, it’s not the same situation.” In many cases, transgendered patients need to meet this criteria and diagnosis in order to access medical intervention and procedures.
“Ultimately, I think it’s a good step, to move away from that language,” she concludes. “But pathologization is the price we pay for the medical interventions we need or want. If we did phase it out and remove the stigma and pathologization, how would we ensure the medical coverage needed?”
In addition to what are generally considered the diagnostic parameters, the DSM also contains Section 3, which outlines conditions that are of interest, but need further research before they can be included as official diagnoses. In the DSM’s newest edition, some of the disorders included in Section 3 are:
Attenuated psychosis syndrome: characterized by hallucinations too mild to be included in another diagnosis.
Internet use gaming disorder: is an addiction to internet gaming.
Non-suicidal self-injury: which includes harmful behaviors such as cutting and / or burning oneself.
Suicidal behavioral disorder: differentiates between suicide attempts and self-harming (both of which are currently symptoms or risks in other disorders, such as depression).
Furthermore, there were some disorders that even though they were brought up or discussed, they were not included in the latest edition at all. These include:
Anxious depression: a combination of depressive and anxiety disorders.
Hypersexual disorder: characterized by compulsive sexual behaviour.
Parental alienation syndrome: where a child compulsively and for no reason belittles and insults one parent, often under the influence of the other parent.
Sensory processing disorder: includes difficulties with processing and responding to sensory information.
Premenstrual Dysphoric Disorder
Previously in the appendix, this disorder has been promoted as its own diagnosis as a depressive disorder. It is essentially what we think of as PMS, but characterized by more severe symptoms of depression and irritability. Considering that there has been controversy regarding the existence of PMS, this is in itself a bold change.
Binge Eating Disorder
Another disorder that was promoted from the appendix, binge-eating disorder is now an eating disorder unto itself. Characterized by compulsive overeating, it is the most prevalent eating disorder in the United States.
Disruptive Mood Dysregulation Disorder (DMDD)
This diagnosis requires a child to have at least three tantrums a week for a one-year period. It can be — and has been — argued that this is simply kids being kids, and is one of the newer disorders that is brought into the discussion of whether we are becoming too diagnose-happy.
Substance Use Disorder
Currently, there are two separate categories of substance use issues: substance abuse and substance dependence. The changes in this edition of the DSM will combine the two categories, but also strengthen the diagnosis by requiring more symptoms than before to fit the criteria.
Excoriation
This disorder is new to the DSM and is characterized by compulsive skin picking. It is now included as part of the Obsessive-Compulsive and Related Disorders chapter.
Hoarding disorder
The behaviour of problematic hoarding has gained notoriety in recent years with the popular show Hoarders but it has not been classified as a disorder in the DSM until now.
Ties to pharmaceutical companies
There is one change in particular in the new version of the DSM that, above all, fuelled controversy surrounding vested interests and conflicts of interest within the psychiatric industry. This was the removal of bereavement exclusion in major depressive disorder. Until now, the diagnosis of depression could not be given to patients that had lost a loved one in the last two months. It is argued — and logically so — that the depression that an individual experiences after a loss is simply natural grief, not a mental disorder to be diagnosed and medicated.
Granted, this change will include a caveat in the checklist criteria for major depression that notes that some of these symptoms are, in fact, just natural responses to circumstance; this being said, it is now easier to diagnose depression and thus easier to prescribe medication for something that can just be a natural response.
Unfortunately, this is not a new concern. A 2006 study at the University of Massachusetts, found that 95 of the 170 DSM panel members (in other words 56 per cent) — who are in charge of discussing the changes made — had one or more financial association with pharmaceutical companies, most often in research funding. The panels dealing with “Mood Disorders” and “Schizophrenia and Other Psychotic Disorders” were made up of pharmaceutical-linked members. This has led to an increased transparency on the panels, with members of the DSM-V Task Force and Work Groups agreeing to receive no “remuneration for their services with the exception of the DSM-V Task Force Chair,” as well as having a limit on the amount of money they can receive from pharmaceutical companies, and how many stocks they can hold in those companies.
Despite an increase in transparency, studies found that, in 2011, 69 per cent of the task force members associated with the DSM-V had ties with pharmaceutical companies, an increase in the past several years. What these studies have noted is that the efforts at transparency — while good first steps — do not adequately mitigate the bias that these financial ties bring to the planning table. The criticism lies in that the focus should be what is best for those suffering from the mental illnesses that are being diagnosed, not what is best for companies that may or may not benefit from the treatment of these illnesses.
We live in a society that seems to be over-medicated and over-diagnosed; however, it is also clear that mental health somehow still remains an under-funded and stigmatized issue. One of the biggest concerns about the newest version of the DSM is that it is medicalizing everyday behaviours and making them disorders when they are not. This takes attention and funding away from individuals whose disorders are legitimately detrimental to their functioning.
The DSM is important to us all because it holds many of the structural guidelines that are used to diagnose and treat mental illness. By making certain changes — such as that to Gender Identity Disorder — we can work to remove the stigma from some marginalized groups, and from some behaviours that are “wrong” only by social construct.
Furthermore, it is notoriously difficult to access mental health resources without the necessary support and documentation. The nuances of diagnosis are important, because they balance between providing individuals who are suffering from mental health issues with relief, while also not further marginalizing them. This is once again where the DSM and the practitioners who use it come in: they have the resources and power to make or break an individual’s mental health. There are many controversies surrounding psychiatry, but in a helping profession such as psychology, the goal should always be to assist those who need it as much as possible.
