Treatment Centers

The American Psychiatric Association (APA) is currently working to upgrade its chief diagnostic tool, the Diagnostic and Statistical Manual (DSM). In doing so, those within the association have opened a discussion about the DSM itself. Is it a living document or a clinical bible? Are the proposed changes in the best interest of patient care or designed to maximize practitioner reimbursement from insurance companies?

As one might imagine, the discussion, now public, at times seems not to be so much an exchange of ideas as an occasion for two sides to continue talking past one another.

The DSM, which is published by the APA, lists diagnostic classifications for mental disorders. The manual also references features which are often associated with each disorder and key criteria for diagnosing disorders. The manual is currently in its fourth version, hence its designation DSM-4. The current controversy within the psychiatric community is over proposed changes in the upcoming DSM-5.

Opposition to some of those proposed changes became public through the posting of an online petition in October. The petition was submitted in the form of an Open Letter to the DSM-5 Task Force. The petition had nearly 5,000 signatories from the mental health profession and organizations active in the mental health field. The APA also received 10,000 comments and 50 million hits on its Website during periods when it invited feedback on DSM-5. So, what are the conflicting issues?

In the words of Dr. David Elkins, who heads up a section of the APA behind the Open Letter, concerns center on the possibility that lowering thresholds for diagnosis may "create false epidemics by pathologizing numerous people who are really just going through the continuum of normal variation of human experience."

To do so could result in a) over-medicating and/or b) unnecessarily stigmatizing people. Many petitioners are concerned about the potential addition of several new disorders such as parental alienation syndrome (PAS), broadened anxiety disorders, and disruptive mood dysregulation disorder. These "new" disorders are insufficiently grounded in research, according to experts. One example is the proposed mild neurocognitive disorder, which could lead to many of our elderly being given prescription medications to combat what should be accepted as the ordinary decline in mental acuity that comes with age.

Interestingly, Dr. Reiger, who heads up the DSM-5 Task Force, agrees with the challenge to scientific research. The DSM-5 finished field trials involving 2,000 patients in October and continues to test in nearly 2,000 clinical practice settings until March of 2012. Nevertheless, Dr. Regier concurs with the notion that some of the proposed disorders lack rigorous study. This is because it is difficult to obtain research dollars for disorders which are outside of the DSM, creating a true catch-22 situation with far-reaching implications.

Dr. Reiger believes that the DSM should be treated as a living document. He has said he would like to see a DSM-5.1, DSM-5.2 and so on, similar to the regular upgrades made to software programs. The ability to assign a clinical diagnosis is important to establish effective treatment, but it is also required in order to receive reimbursement from insurance companies.

For whose ultimate benefit is a living document? In layman’s terms, this may be a battle within the psychiatric community about which is better – a conservative versus an encompassing approach to medical practice. Or it could be largely financially motivated. During the process, everyone, including patients, will benefit from an ongoing dialog that is frank and transparent.