Diagnostic and Statistical Manual of Mental Disorders

The long-awaited new edition of the Diagnostic and Statistical Manual of Mental Disorders—DSM-5 for short—angered some mental health professionals and patient advocates, both for what it included and didn't include, when it was released by the American Psychiatric Association in May 2013.

For years, the DSM has been known as the "psychiatrist's bible." It affects more than just the diagnosis of mental illness—it's used in determining insurance benefits and disability, affects the availability of special education and social services, and is a staple in court proceedings.

This latest edition, the fifth, had been several years in the making—years that saw extreme controversy about some of the proposed changes. Some members of the committees working on the new volume even resigned in protest of particular changes.

The DSM lists criteria for diagnosing such things as psychotic disorders (like schizophrenia), mood disorders (like bipolar), anxiety disorders, personality disorders (like antisocial personality disorder), trauma- and stressor-related disorders (such as PTSD), and many, many more.

For each disorder, there's a list of specific symptoms and behaviors that must or must not be present in order for the illness to be diagnosed. Usually, a certain number of the listed items must be present, rather than all of them.

For example, in bipolar disorder, in addition to the mood disturbance, three to four of these seven symptoms or behaviors have to be present in order to diagnose the condition:

1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. More talkative than usual, or pressured speech
4. Easily distracted
5. Increase in goal-directed activity
6. Excessive involvement in risky activities

There was a big public outcry when four separate autistic disorders that had been listed in the fourth edition of the DSM, including Asperger's Syndrome, were combined into a single illness, Autism Spectrum Disorder, for the DSM-5. Patients currently diagnosed with Asperger's and their parents feared losing social and educational services. However, it's not clear if this has occurred since the change in the DSM was made.

Others in the mental health community were bitterly opposed to including an illness that was in the previous version, Oppositional Defiant Disorder (ODD). The diagnosis involves children and teens who talk back to parents and teachers, who sometimes refuse to obey authority figures, and who lose their tempers easily, labels that child or teen "mentally ill" unnecessarily.

What was not added was a diagnosis for pediatric bipolar disorder (also called child-onset bipolar disorder, or COBPD). Instead, a new diagnosis was created called Disruptive Mood Dysregulation Disorder (DMDD). This disorder focuses on frequent, severe temper outbursts and overall irritability or anger between them.

Disruptive Mood Dysregulation Disorder can be diagnosed along with Major Depressive Disorder (MDD), but not with bipolar disorder. If you look at the symptoms of bipolar disorder in children, as combined by childhood bipolar experts Demitri Papolos, MD, and his wife Janice Papolos, you will see some similarities and some differences between these and those of a child diagnosed with both DMDD and MDD.

National Institute of Mental Health Director Dr. Thomas Insel didn't appear to like the DSM-5's approach, at least initially—he said as the DSM-5 was released in 2013 that going forward, "NIMH will be re-orienting its research away from DSM categories," with the objective of developing a system that includes genetics, biomarkers, brain scans and other physical aspects of and testing for mental illnesses.

Insel wrote, "While DSM has been described as a 'Bible' for the field, it is, at best, a dictionary, creating a set of labels and defining each." Criticizing the "validity" of the DSM, Insel appeared to some to be withdrawing all support for the DSM-5.

However, just two weeks later a press release issued by NIHM and written jointly by Insel and Jeffrey A. Lieberman, M.D., President-elect, APA, clarified Insel's earlier blog post. In particular, the press release says:

Today, the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), along with the International Classification of Diseases (ICD), represents the best information currently available for clinical diagnosis of mental disorders. Patients, families, and insurers can be confident that effective treatments are available and that the DSM is the key resource for delivering the best available care. The National Institute of Mental Health (NIMH) has not changed its position on DSM-5.

However, NIMH still has plans to go forward with developing a more physically based diagnostic system, although the agency acknowledges that this is a long-term project. Future research in the field will need to be "based on dimensions of observable behavior and neurobiological measures" in order to qualify for NIMH grant funding.