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Proposed mental health manual revisions spark controversy

by Alexandra Gallucci
Feb 02, 2012


Alex Gallucci/MEDILL

The American Psychiatric Association is scheduled to release the Diagnostic and Statistical Manual of Mental Disorders-V in 2013. The current DSM-IV was published in 1994.

Approximately one million people diagnosed with Asperger’s syndrome may lose that diagnosis next year with the release of the Diagnostic and Statistical Manual of Mental Disorders V, a working bible to psychiatrists and psychologists.

Asperger’s syndrome, the developmental disorder resembling autism, is just one diagnosis in a laundry list of disorders that may be removed. The changes have many speculating over what this will mean for those who are affected by them.

“In general, it’s always been a moving target that as we learn more and get better information, we revise our way of classifying mental disorders,” said Dr. Sidney Zisook, a clinical psychiatrist and director of residency training at the University of California San Diego.

Revising the manual is a highly involved and expensive effort, said Dr. Mark Zimmerman, a clinical psychiatrist and associate professor of psychiatry at Brown University in Providence, R.I. The revisions are currently in a long process of discussion, but DSM-V will not be released until sometime in 2013. The last round of revisions was completed with the release of DSM-IV in 1994.

Besides wanting the manual to reflect the most up-to-date research, Zimmerman noted that one cannot ignore the potential financial outcomes realized by the American Psychiatric Association with coming out with a new version of the manual.

“With each new edition of the DSM we have witnessed repeated instances of changes being made in the absence of sufficient data demonstrating that the new criteria are superior to the prior,” said Zimmerman’s study, published in the Journal of Clinical Psychiatry Jan. 24.

The study researched the impact of the proposed elimination of five personality disorders from DSM-V. The study sought to answer the question of how many individuals would no longer be diagnosed with a personality disorder if the diagnoses of paranoid, schizoid, histrionic, narcissistic, and dependent personality disorders were removed.

One of the risks of deleting the disorders is the loss of clinical information that pertains to those patients with a removed disorder, Zimmerman said. “Will these people be less adequately treated?” he asked. He said that at this point, the implications of deleting certain personality disorders are uncertain.

Another debate concerns the removal of the bereavement exclusion, a condition that exempts a grieving individual from a diagnosis of depression. Under the current DSM-IV, a patient is granted a period of two months of “normal” grieving after the loss of a loved one. If a patient exhibits five or more characteristics of depression beyond two months, they are given a diagnosis of depression.

Jerome Wakefield, a clinical social worker and professor of social work at New York University, investigated the association between grief and depression in his 2007 paper published in the Archives of General Psychiatry.

He has advocated for the extension of the bereavement exclusion, which currently grants a period of two months of grieving, beyond which the patient is considered to have a diagnosis of depression. “The evidence I have is that two months is too short,” said Wakefield. The bereavement exclusion was shortened from one year to two months in 1994 with the release of DSM-IV.

But Zisook held that  “excluding people from the diagnosis of depression because they are bereaved is not valid.” 

He is particularly concerned with the links between depression and suicide, and said that mental health practitioners should err on the side of caution when it comes to diagnosing depression. “It is not the time to ignore the possibility of a diagnosis of depression, but to be alert to this diagnosis," he said.

Both Zisook and Wakefield agreed that assigning a period of two months to distinguish between bereavement and depression is arbitrary.

Steven Migalski, a clinical psychologist and professor at the Adler School of Professional Psychology in Chicago, addressed the debate over the proposal to change the definition of autistic spectrum disorders. Many people are concerned about the implications of the removal of Asperger’s syndrome from the list.

“The recommendation is that we move away from specific language of Asperger’s to the broader language of autistic spectrum disorders,” he said.

Those patients will be reevaluated to determine whether or not clinical significant distress or clinical significant impairment continues to be maintained as a result of their symptoms.

“There are a lot of questions of what will happen when DSM-V is applied for those who no longer meet the criteria,” Migalski said. He said the purpose of the revisions is to try to decide if there is better language to describe the disorders and conceptualize them differently.

Patients who no longer meet the criteria of an autistic spectrum disorder in DSM-5 will be reevaluated to determine if they continue to experience clinically significant distress or impairment as a result of their symptoms, Migalski said.

He contended that is the job of clinical psychologists to educate the public in terms of the DSM and how it is used.