DSM-5 Like it or hate it's what we have

The imminent new edition of the Diagnostic and Statistical Manual of Mental Disorders 5 may hurt confidence in psychiatric diagnosis. The update includes new diagnoses and perhaps, controversially, reductions in thresholds for old ones that will possibly inflate the already strained boundaries of psychiatry. How the new edition will sustain robust research in the field is now a hotly debated concern. But more so, it’s entirely possible that following the DSM 5 may lead to over-diagnosis and as one consequence over-medication.

It should be said that it’s with fortune that some of the DSM 5’s more contentious proposals were eventually dropped under external pressure. These included, amongst others  “psychosis risk”, mixed anxiety/depression, internet and sex addiction, cumbersome personality ratings.

I for one would have preferred further delay in the roll-out of this edition and have the APA more properly field test this edition increasing much needed opportunity for quality control.

Pathologizing Grief

I’ve been known to pluck the DSM IV off my bookshelf every now and then, and for many, it’s a staple item for all things psychiatric and diagnostic. And soon I’ll be looking forward to the DSM-5.

But, as many are aware, a proposal to medicalize or pathologize grief is attracting significant opposition and criticism.

The DSM 5 would encourage the diagnosis of Major Depressive Disorder almost immediately after the loss of a loved one — having just 2 weeks of sadness and loss of interest along with reduced appetite, sleep, and energy would earn the Major Depressive Disorder label.

Many will say normal grief is not 'Major', is not 'Depressive,' and is not 'Disorder.' Grief is the normal and necessary human reaction to love and loss. One critique asks Why not make "thinking clearly" a mental illness?

One bothersome thought is that anyone who has experienced both severe depression and intense grief knows they are not the same thing. A grieving person might become depressed, but that means they were not depressed to begin with. It is questionable if antidepressants would do much for grief.

Pathological internet and video game misuse

Jack Dikian

November 2011

Video game and internet addiction is becoming an increasingly difficult problem. Parents will tell you that it’s affecting the everyday life and social situations of adolescents and young adults. As well, it can hinder a child's learning skills, cause real life problem solving to become more difficult, and cause a child to spend far less time with family and friends.

More and more families are flooding psychiatrists with pleas for help for children hooked on Video games and the Internet.

The condition, now known as "pathological internet misuse" is growing so rapidly among adolescents and young adults that it could soon be formally recognised as a mental health disorder.

Video game addiction is excessive or compulsive use of internet, computer and video games that interferes with daily life. Instances have been reported in which users play compulsively, isolating themselves from family and friends or from other forms of social contact, and focus almost entirely on in-game achievements rather than other life events.

There is no formal diagnosis of video game addiction in current medical or psychological literature, albeit, Inclusion of it as a psychological disorder has been proposed and rejected for the next version of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

In Australia, a website would be launched this week to help carers, families and counsellors address the growing and complex problem of internet and gaming (video) addiction. The Network for Internet Investigation and Research in Australia will be run by specialists with a "common passion in assessing, treating, researching and educating the public and professionals" about internet addictions.

The Chinese Classification of Mental Disorders and global unification

Jack Dikian

November 2011

A few days ago I put together a sketchy summary describing the evolution of the Diagnostic and Statistical Manual of Mental Disorders (DSM) over the last 100 years or so. In doing so, the idea that the DSM schema as in any other purpose-build manual represents the social constructs and states of distress that have local biopsychosocial sources of the day becomes plainly obvious.

If for example the DSM, amongst other things, is so organized such that it legitimatises remuneration to practitioners from private medical insurance and government programs – which it does, then that particular social use may be immaterial in countries and societies where health care is financed differently.

This is illustrated in the Chinese Classification of Mental Disorders (CCMD) system which includes diagnostic categories which are more specific to Chinese or Asian culture such as Koro, an excessive fear of the genitals and women’s breasts shrinking or drawing back in to the body. Another, Zou huo ru mo the perception of uncontrolled flow of qi in the body. The DSM’s diagnosis of borderline personality disorder becomes impulsive personality disorder in the CCMD-3.

Local applications aside, it is a testament to the global flow of information technology and China’s more preparedness for openness that the CCDM-3 is marked with greater global unification and international usage of diagnosis and coding.

Psychiatric classifications over the years

Jack Dikian

November 2011

Not long ago I came by a 1968 publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM-II). The first thing that struck me, although I wasn’t too surprised, was its size. It’s 134 pages in total and lists 182 disorders. Compare this to what is on my desk - DSM-IV (1994) 886 pages and 297 disorders. The next version of the DSM, DSM-5 will be due for publication in May 2013.

Over the years the DSM has attracted controversy and criticism as well as praise. Some critics argue that the DSM represents an unscientific system that enshrines the opinions of a few powerful psychiatrists. I for one am interested in how those involved in reaching consensus and publishing the DSM over the years have had to react to, and be informed by evolving social norms, public perceptions, labels, and of course field trials, diagnoses reliability checking and other influences.

I wanted to put together a time-line reflecting key milestones or versions of the DSM, its size, estimate of the number of classifications as well as key historic backdrops. This is in no way comprehensive, however may be useful nevertheless.

Version	Year	Pages	No of Diagnoses	Remarks
	1840		1	The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. The first official attempt was the 1840 census which used a single category, "idiocy/insanity".
Guide	1917		22	A new guide for mental hospitals called the "Statistical Manual for the Use of Institutions for the Insane",
DSM-I	1952	130	106	World War II saw a large-scale involvement of US psychiatrists in the selection, processing, assessment and treatment of soldiers – thus shifting the focus away from mental institutions and traditional clinical perspectives. At the same time an APA Committee undertook to standardize the diverse and confused usage of different documents.
DSM-II	1968	134	182	The DSM-II as in earlier versions reflected the predominant psychodynamic psychiatry. Symptoms mostly seen as reflections of broad underlying conflicts or maladaptive reactions to life problems, rooted in a distinction between neurosis and psychosis.
DSM-II Seventh Printing	1974			The seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder and the diagnosis was replaced with the category of "sexual orientation disturbance".
DSM-III	1980	494	265	A controversy emerged regarding deletion of the concept of neurosis, a mainstream of psychoanalytic theory and therapy. “Neurosis” was reinserted in parentheses after the word “disorder” in some cases. Also, the diagnosis of ego-dystonic homosexuality replaced the DSM-II category of "sexual orientation disturbance".
DSM-III-R	1987	567	292	Controversial diagnoses such as pre-menstrual dysphoric disorder and masochistic personality disorder were considered and discarded. Also, “Sexual orientation disturbance" was also removed and was largely subsumed under "sexual disorder not otherwise specified".
DSM-IV	1994	886	297	A major change from previous versions was the inclusion of a clinical significance criterion to almost half of all the categories, which required symptoms cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning”.
DSM-IV-TR	2000			The text sections giving extra information on each diagnosis were updated, as were some of the diagnostic codes to maintain consistency with the ICD.

DSM-5

It will be interesting to see the final product, its size, and more importantly the handling of a large number of revision areas. I look forward to, for example, the treatment of Neurodevelopmental Disorders, previously under Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence and Anxiety Disorders.

The American Psychiatric Association provides an official DSM-5 Development Website at: http://www.dsm5.org/pages/default.aspx