Inside the Controversy Over the Bible of Mental Disorders

The Diagnostic and Statistical Manual of Mental Disorders has just undergone a five-year revision process, and it was not as dull as it sounds. Not nearly.

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The Diagnostic and Statistical Manual of Mental Disorders is "the so-called bible of mental disorders," explains Benedict Carey, who writes of the recent approval of the fifth edition of the manual by the board of trustees of the American Psychiatric Association in a piece in Tuesday's New York Times. While this new manual, DSM-5, won't be released until May of 2013, marking "one of the most anticipated events in the mental health field" according to the American Psychiatric Association website, there's been an air of swirling controversy and drama surrounding the update since it began five years ago. The update process was not, in a word, dull.

As Carey writes of the committees working on the revision: "They plotted a revolution, fell to debating among themselves, and in the end overturned very little except their own expectations" during years of "sometimes acrimonious, and often very public, controversy." The doctors appointed to update the manual, for instance, had taken the responsibility into Web-friendly territory, posting online proposals for changes in definitions (of depression and Asperger syndrome, for example) which the public then weighed in on—patient advocacy groups and outside academic researchers objecting vociferously to certain changes, and several committee members abandoning the work in protest.

The revision process was a rather massive undertaking, per the American Psychiatric Association's website: "The last stage of the manual’s development began in late June 2012 at the end of a six-week open-comment period for health professionals, patients and families, advocates and others. Throughout the three open-comment periods, which began in 2010, we have received more than 13,000 comments and more than 12,000 emails and letters from you, our readers." Now, "Changes to disorders and diagnostic criteria, based in part on the latest comments received, will be made through the fall."

Opinions on the final text, as with the many opinions offered throughout the process, vary. As Carey writes, some psychiatrists feel that a "solid job" has been done, particularly given the inherent difficulty of objective lines being drawn in the field. Others, like Dr. Allen Frances, who was chair of the DSM-IV Task Force, disagree. He wrote in a post for Psychology Today that the new version is a "deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound," advising doctors to "ignore the ten changes that make no sense." Others still say DSM5 is not "radically different from the previous version, and its lessons more mundane than the rhetoric implied," writes Carey. 

Though premenstrual dysphoric disorder, binge-eating, and hoarding are now listed as their own disorder entries, the main controversies were over changes to the diagnoses of depression, autism, and pediatric bipolar disorder. For example, the group working on the depression definition pushed to get rid of the "bereavement exclusion," which stipulates that those coping with the loss of a loved one are not clinically depressed; others argued that the bereaved should not be diagnosed with clinical depression. Carey writes, "In the end the committee cut a deal. It eliminated the grief exclusion but added a note in the text, reminding doctors that any significant loss — of a job, a relationship, a home — could cause depressive symptoms and should be carefully investigated."

With autism, the committee wanted to get rid of related labels, like Asperger's, proposing a "single 'autism spectrum disorder' category" to make the parameters of diagnoses more clear. Yale School of Medicine's Fred Volkmar quit the committee in protest over that, claiming (backed by research) that the revision would likely fail to recognize 45 percent of those currently diagnosed with autism or autism-related diagnoses (who might therefore not get the treatment they needed). It was argued in return that only 10 percent of people would be excluded from said diagnoses. Ultimately the committee decided on a sort of a grandfathering fix, with anyone who'd previously had an autism or autism-related diagnosis being included.

And with pediatric bipolar disorder, a diagnosis that had been given to kids as young as two (and which research found most of those children didn't really have), the committee engaged in extensive debate over what to call what was actually happening. They eventually landed on D.M.D.D., or "disruptive mood dysregulation disorder," which the experts agree may not be perfect, but is a start.  That the process was so complicated, though, is perhaps fitting to the reality of what's being created. As Carey writes, "From beginning to end, many experts said, the process of defining psychiatric diagnoses is very much like finding the right one for an individual: it’s a process of negotiation, in many cases."

In the future, the committee plans to update the book more regularly, but given what's inside, this process may never be easy, exactly. 

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