Sunday, 28 April 2013

DSM V


DSM V and CAMHS

 

The publication of DSM V in 2013 (The Diagnostic and Statistical Manual) used by Psychiatrists and others in CAMHS contexts to assess and diagnose troubled young people is a significant event. But even before it was published it was attracting controversy and criticism as its development was monitored. 70 per cent of the DSM V taskforce had commercial links to the pharmaceutical industry creating potential conflicts of interest. In addition, part of their taskforce membership was a mandatory nondisclosure agreement- effectively shrouding the whole process in secrecy and preventing any challenge from concerned clinicians.

Allen Frances, a former head of DSM IV issued strongly worded criticisms of the processes leading to DSM-5 and the risk of "serious, subtle,...ubiquitous" and "dangerous" unintended consequences such as new "false 'epidemics'". (1). He stated that "the work on DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology" and is concerned about the task force's "inexplicably closed and secretive process."

Robert Spitzer, the head of the DSM-III task force, also publicly criticized the way DSM V has been secretive and not open to scrutiny. (2). And Christopher Lane (3) former director of the Psychoanalytic Studies Program in the Psychiatry Department of Emory University, warned against the expansion of mental illness categories which were pathologising normal human experiences.

The British Psychological Society stated in its June 2011 response that it had "more concerns than plaudits" (4). It criticized proposed diagnoses as "clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements... not value-free, but rather reflecting current normative social expectations". The BPS noted doubts over the reliability, validity, and value of existing criteria, that personality disorders were not normed on the general population, and that "not otherwise specified" categories covered a "huge" 30% of all personality disorders.

It also expressed a major concern that "clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences... which demand helping responses, but which do not reflect illnesses so much as normal individual variation".

 

Who decides what is abnormal: the worker, parent or child? How is the notion of sufficiently marked or prolonged measured and against what standard? Mental illness takes us into the realm of medicine and clinical guidelines and diagnostic criteria usually applied to the most serious difficulties and those that are statistically rare. Whereas, at the other end of the scale, the terms emotional well-being or emotional literacy are becoming popular among the wider public and professionals even though it would be hard to find agreement about a definition of what these terms mean.

 

The behaviour and emotional affect of children and young people designated with symptoms of mental health difficulty can be considered in different ways within a variety of professional discourses. The dominant discourse is that of medicine and especially psychiatry, which continues to refine classifications of symptoms into universal descriptors. Yet behaviour and expressed emotions can be interpreted widely, depending on the theoretical base of the professional involved and the specific cultural and historical context of their manifestation.

 

Mental illness in young people was constructed in the context of a debate among

psychiatrists about the criteria for diagnosing specific mental health problems. Previously they had relied on a constellation of symptoms based on adult measures to distinguish children and adolescents whose condition was outside the normal experience. A significant study drew attention to the limitations in psychiatric diagnosis and, by implication, the medical model it embodies (5) This study found that not all children with symptoms of mental disorder showed marked impairment and, conversely, some children had significant psychosocial impairment without reaching the clinical threshold for diagnosis.

 

 

In 1952, when the APA's diagnostic manual first appeared, it was a small text that offered sketches of such traits as passive-aggressive personality disorder, emotionally unstable personality disorder, and inadequate personality disorder. It was seen more as a guide to psychiatry than as a definitive authority on everything pertaining to mental health. But in 1980, with publication of the third edition, which included more than 100 new mental disorders, quite a few of them still being contested. In 1994 DSM IV culminated in many disorders deleted, created or reorganised based on empirical research and literature reviews. The evidence base informing DSM IV included very little testimony from patients or service user organisations, and young people were not consulted at all.

 

For CAMHS staff the major changes in DSM V include the elimination of Asperger syndrome as a separate disorder, and merged under autism spectrum disorders (ASD). Under the new classification, clinicians would rate the severity of clinical presentation of ASD as severe, moderate or mild. But how are these terms defined? This change has been met with resistance amongst Asperger Syndrome specialists. There has been a proposal to increase the diagnostic criteria for the age when symptoms became present. The proposal would change the diagnostic criteria from symptoms being present before seven years of age to symptoms being present before twelve years of age.

 

The diagnosis of Bipolar Disorder in children is a controversial topic. While some believe the DSM IV criteria should be retained others have proposed other behavioral markers specific for children. The DSM-5 may include a new type of mood and conduct disorder, Disruptive Mood Dysregulation Disorder, as a replacement for most peadiatric bipolar diagnoses. Some prominent psychiatrists, such as Dr. Stuart Kaplan and Dr. Allen Frances, advocate applying less severe and better-researched diagnoses such as ADHD and Oppositional Defiant Disorder instead of Peadiatric Bipolar Disorder.

 

Another origin for controversy is the rise in the number of diagnoses in recent years, almost exclusively in the USA, with several possible causes for this increase. It has been argued that factors including biomedical reductionism, neglect of trauma and attachment factors, the symptom checklist but decontextualised model of psychiatry embodied in DSM, and the pervasive influence of the pharmaceutical industry, particularly in the US health system, have contributed to the epidemic of Peadiatric Bipolar Disorder.

 

Hypersexual Disorder is proposed as a new category. The diagnosis would apply when a person experiences several of the indicated symptoms (extreme amounts of time spent in the sexual activity, using the sexual activity in response to low mood or stress, failed attempts to reduce the behaviors, etc.). Moreover, it would apply only when the problem lasted six months or more, when a person experienced significant distress or impairment in major life areas because of it, and when the problem was not directly caused by medication or drugs, as well as other criteria.

It is proposed that the eight symptoms of Oppositional Defiant Disorder should be divided into the following categories: Angry/Irritable Mood; Defiant/Headstrong Behavior; and Vindictiveness. However, just as in the DSM IV, four of these symptoms need to be present to meet diagnostic criteria. The minimum four symptoms can come from all (or even just one or two) of the three categories. But who defines vindictiveness compared to say- retaliation, or an indication of persecutory child sexual abuse?

DSM V will have added to the diagnostic criteria for Oppositional Defiant Disorder stating that for children under 5 years of age, oppositional behavior "must occur on most days for a period of at least six months". But what does 'most' mean? For children 5 years or older, oppositional behavior "must occur at least once per week for at least six months". The current criteria states that four or more symptoms must be present for at least 6 months. The proposed change adds the criterion of frequency of symptoms and also delineates required frequency by the age of the child.

Gender Identity Disorder in children is another controversial area in DSM V. Transgender support groups and organizations believe it is unethical to even have a diagnosis of GID in young people. Other critics argue that it pathologises non-conformity with orthodox binary definitions of gender, stigmatises many children and fails to tackle homophobic prejudice and social intolerance of difference which are the real problems.

DSM V and all its predecessors are peppered with distinctions such as 'severe' 'major',  'superficial' and 'short-term', to try and help users place the young person into a pre-formed category. The problem is that these terms are rarely defined and by their nature are influencing the perceptions of psychiatrists and others tasked with assessing troubled young people. They force clinicians to find a category for the young person rather than permit a more personal, descriptive assessment. This means in the final analysis they are highly subjective. Labels stick and are usually linked to treatment including medication which can have profound side effects and imply that there is a biological element to a young person's distress. This risks ignoring the social construction of mental illness, the socio-economic context of racism, homophobia, poverty, poor housing, parental mental illness, unemployment and bullying.

Steven Walker, Systemic Psychotherapist

 

References

 1. Allen, F. (2009). A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences, Psychiatric Times, 26: 8

 


 

3. Lane. C. (2009). Bitterness, Compulsive Shopping, and Internet Addiction

The diagnostic madness of DSM-V. Slate Magazine, July 2009.

 

4.  British Psychological Association.(2011). Response to the American Psychiatric Association: DSM-5 Development. June 2011.

 

5. Pickles, A; Rowe, R; Simonoff, E; Foley, D; Rutter, M; and Silberg, J.(2001).Child Psychiatric symptoms and psychosocial impairment- relationship and prognostic significance. British Journal of Psychiatry, 179. 230-235