The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders is the final word on the diagnosis and treatment of psychology and psychiatry in the United States. Clinicians, researchers, pharmaceutical regulatory bodies, lawmakers and insurance companies all use the DSM for arbitration and guidance. The DSM is effectively the Bible for mental health care providers in America, and every release of it is naturally subject to criticism. The most recent version, DSM-5, released on May 18, 2013, is no exception.
The Importance of the DSM
Historically, the DSM has exerted a huge amount of influence over the practice of American mental health care, and American culture and society at large. For example: the inaugural version, DSM-I (released in 1952), classified homosexuality as a “sociopathic personality disturbance”, and medical professionals thus considered homosexuals to be mentally disordered. When the APA published the seventh printing of DSM-II in 1974, homosexuality was no longer considered an aberrant mental state of mind, a decision that has constantly been a weapon in the arsenal of the the gay rights movement.
Planning for DSM-5 started as far back as 1999 (five years after the publication of DSM-IV), when the American Psychiatric Association and the National Institute of Mental Health formed a task force to establish the research priorities for DSM-IV’s successor. Special focus was given to covering gender issues, mental disorders in the elderly, and mental disorders among infants and children.
Changes and Criticism in DSM-5 Criteria
One of the hopes for DSM-5 was that it would address criticisms that previous versions were too all-encompassing in scope, so much so that 1 in every 4 Americans could be considered afflicted by a mental illness – even if the distinction was so slight as to consider, for example, normal feelings of sadness as a precursor to clinical depression (a criticism that persists today).
DSM-5 no longer considers Asperger’s Syndrome a separate classification, instead folding it back into the overall umbrella of autism-related disorders (and, in doing so, antagonizing various autism communities and support groups who feel that Asperger’s is distinct enough from autism to warrant its own category).
Similarly, the decision to drop “bereavement exclusion” from the depressive disorder section has resulted in a backlash from those who fear that the natural process of grieving over the death of a loved one will now be classified as mental depression. The exclusion refers to the practice of exempting mourning friends and family members from mental evaluation for two months following the death that triggered their grieving, unless their grieving causes harm to themselves or others. A psychiatrist at New York University feels that DSM-5 dropping the bereavement exclusion will lead to stigmatization of “intense, negative feelings”, even within appropriate contexts.
The National Institute of Mental Health vs. DSM-5
The criticisms surrounding the DSM-5 have caused the National Institute of Mental Health no end of grief of their own. In April 2013, the director of the institute wrote that “Patients with mental disorders deserve better” than the “lack of validity” presented by DSM-5. The Huffington Post attributed this to DSM-5 offering inconsistent treatment guidelines, non-discrete categorization that allows for the same symptom appearing across multiple diagnoses, and not accounting for comorbidity, the presence of additional disorders.
Amid uproar and headlines that NIMH was withdrawing support for DSM-5 (Psychology Today called the move “a humiliating blow” to the American Psychiatric Association), the National Institute of Mental Health attempted some damage control, issuing a joint statement with the President-elect of the APA that DSM-5 is the best resource for mental health in America, and that NIMH supports it.
New Disorders in DSM-5
One of the additions to DSM-5 is Internet addiction, the classification that people who spend an excessive amount of time online – playing games, browsing social media networks – demonstrate the same symptoms as individuals suffering from other addictive disorders. These include an increased amount of time spent at the activity (in this case online), an intense desire to get back online when not using a computer, hiding or lying about Internet usage, deteriorating social, academic or family engagement due to time spent on the Internet, and physical changes as a result of extreme Internet usage (weight gain or loss, back problems, worsening eyesight, etc.), among other symptoms.
DSM-5 also considers hoarding disorder, “persistent difficulty discarding or parting with possessions, regardless of their actual value”, to be its own category, no longer simply an obsessive-compulsive disorder. As with all addictive disorders, a hoarding disorder will be defined by the financial, emotional and societal effects on the hoarder, as well as the people in his or her life.
Disruptive Mood Dysregulation Disorder is one of the more controversial additions to DSM-5. The new diagnosis for children acting out will result in simple temper tantrums being classified as a mental illness, fears Duke University Psychiatrist Allen J. Frances, who headed the task force that put together DSM-IV. In fact, Frances suggested that parents and child psychologists ignore DSM-5’s classification of Disruptive Mood Dysregulation Disorder. However, proponents of the change feel that the creation of the new category can help children who have been misdiagnosed as bipolar (and given incorrect treatment as a result).
Sex addiction – or, in DSM lingo, hypersexuality – has a troubled history with the DSM, being included and excluded from previous versions of the manual. DSM-5 tentatively welcomes it back, but with the caveat that further research is required for full inclusion (or definite exclusion) from future manuals. Past DSM task forces have been leery of classifying hypesexuality as a disorder, since there is no standard measure by which too much sex is considered mentally harmfully excessive.