Blog open to all young people and those trying to help and support them through psychological issues, mental health problems and crisis points in their lives. Provides expert knowledge, information and advice from informed practice, research and publication.
Sunday, 28 April 2013
DSM V and
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
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."
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.
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
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".
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.
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
illness in young people was constructed in the context of a debate among
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.
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.
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
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
instead of Peadiatric Bipolar Disorder.
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.
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.
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?
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.
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.
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.
Walker, Systemic Psychotherapist
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
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