# DSM-5 has been finalized



## David Baxter PhD (Dec 2, 2012)

*The DSM-5 has been finalized*
 by Vaughan Bell
December 2, 2012



It?s  arcane, contradictory and talks about invisible entities which no-one  can really prove. Yes folks, the new psychiatric bible has been  finalist.

 The American Psychiatric Association have just announced that the new diagnostic manual, to be officially published in May 2013, has been approved by the board of trustees.

 You can read the official announcement and a summary of the major changes online as a PDF  ? and it seems a few big developments are due.

 The various autism-related disorders have been replaced by a single  ?autism spectrum disorder? ? essentially removing Asperger?s from the  manual.

 A ?disruptive mood dysregulation disorder? has been added to  ?diagnose children who exhibit persistent irritability and frequent  episodes of behavior outbursts three or more times a week for more than a  year?.

 As the APA admit, this is largely to address the rise of the  ?childhood bipolar disorder? concept which has led to a huge number of  children with challenging behaviour being medicated on rather  ill-defined grounds. Whether this actually does anything to change this,  is another matter.

 Despite the expected revision of the overly complex and often  indistinguishable subtypes of personality disorder ? these have been  kept as they were.

 Post-traumatic stress disorder has been tinkered with ? apparently to  pay ?more attention to the behavioral symptoms? and presumably to  exclude ?PTSD after seeing things on the TV? ? a change included in all  the drafts.

 Perhaps most controversially, the bereavement exclusion will be  removed from the diagnosis of depression ? meaning you could be  diagnosed and treated for depression just two weeks after a loss if you  fulfil the diagnostic criteria.

 If you want to examine the changes yourself ? tough luck ? the APA have removed all the proposed criteria off the DSM-5 website.  This is supposedly to ?avoid confusion? but most likely because the  manual is a big money-maker and the finished product will be on sale in  May 2013.

 But diagnostic developments aside, we can also expect some changes simply from the benefit of hindsight.

 Most clinicians will learn enough of the new manual to ensure they  look cutting-edge for a few months after publication and then ignore the  new diagnoses and use the same ones they?ve always had vaguely stored  in their heads.

 Researchers will go through an extended period of academic willy  waving where they attempt to outdo each other through their wide and  extensive knowledge of dull and irrelevant details. 

 The APA will keep underlining how we?re now in a new era of science  thanks to the science behind the new manual of science that turns  everything it touches into pure, definitely not insecure, science.

 And finally, the chairman of the DSM-5 committee will begin the  traditional process of becoming disillusioned and publicly denouncing  each step in the development of the DSM-6.

 It?ll be as if the past never happened.


 PDF of APA announcement of finalized DSM-5  
Link to APA announcement in _Psychiatric News_


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## David Baxter PhD (Dec 2, 2012)

*'Asperger's disorder' being dropped from psychiatrists' diagnostic guide*

*'Asperger's disorder' being dropped from psychiatrists' diagnostic guide*
By Lindsey Tanner, MSNBC News
December 2, 2012

The now familiar term "Asperger's  disorder" is being dropped. And  abnormally bad and frequent temper tantrums will  be given a  scientific-sounding diagnosis called DMDD. But "dyslexia" and other   learning disorders remain.

The revisions come in the first major  rewrite  in nearly 20 years of the diagnostic guide used by the nation's  psychiatrists.  Changes were approved Saturday.

Full details of  all the revisions will  come next May when the American Psychiatric  Association's new diagnostic manual  is published, but the impact will  be huge, affecting millions of children and  adults worldwide. The  manual also is important for the insurance industry in  deciding what  treatment to pay for, and it helps schools decide how to allot  special  education.

This diagnostic guide "defines what constellations of  symptoms"  doctors recognize as mental disorders, said Dr. Mark Olfson, a  Columbia  University psychiatry professor. More important, he said, it "shapes   who will receive what treatment. Even seemingly subtle changes to the  criteria  can have substantial effects on patterns of care."

 Olfson was not  involved in the revision process. The changes were  approved Saturday in suburban  Washington, D.C., by the psychiatric  association's board of trustees.

The aim is not to expand the  number of people diagnosed with mental  illness, but to ensure that  affected children and adults are more accurately  diagnosed so they can  get the most appropriate treatment, said Dr. David Kupfer.  He chaired  the task force in charge of revising the manual and is a psychiatry   professor at the University of Pittsburgh.

One of the most hotly  argued  changes was how to define the various ranges of autism. Some  advocates opposed  the idea of dropping the specific diagnosis for  Asperger's disorder. People with  that disorder often have high  intelligence and vast knowledge on narrow subjects  but lack social  skills. Some who have the condition embrace their quirkiness and  vow to  continue to use the label.

And some Asperger's families opposed   any change, fearing their kids would lose a diagnosis and no longer be  eligible  for special services. But the revision will not affect their education  services, experts say.

The  new manual adds the term "autism spectrum  disorder," which already is  used by many experts in the field. Asperger's  disorder will be dropped  and incorporated under that umbrella diagnosis. The new  category will  include kids with severe autism, who often don't talk or interact,  as  well as those with milder forms.

Kelli Gibson of Battle Creek,  Mich.,  who has four sons with various forms of autism, said Saturday  she welcomes the  change. Her boys all had different labels in the old  diagnostic manual,  including a 14-year-old with Asperger's. "To give it separate names  never made sense to me," Gibson said. "To me, my children all had autism." Three  of her boys receive special education services in public school;  the  fourth is enrolled in a school for disabled children. The new autism   diagnosis won't affect those services, Gibson said. She also has a  3-year-old  daughter without autism.

People with dyslexia also  were closely watching  for the new updated doctors' guide. Many with the  reading disorder did not want  their diagnosis to be dropped. And it  won't be. Instead, the new manual will  have a broader learning disorder  category to cover several conditions including  dyslexia, which causes  difficulty understanding letters and recognizing written  words.

   The trustees on Saturday made the final decision on what  proposals  made the cut; recommendations came from experts in several work groups   assigned to evaluate different mental illnesses.

 The revised guidebook  "represents a significant step forward for the  field. It will improve our  ability to accurately diagnose psychiatric  disorders," Dr. David Fassler, the  group's treasurer and a University  of Vermont psychiatry professor, said after  the vote.

 The shorthand name for the new edition, the organization's  fifth  revision of the Diagnostic and Statistical Manual, is DSM-5. Group  leaders  said specifics won't be disclosed until the manual is published  but they  confirmed some changes. A 2000 edition of the manual made  minor changes but the  last major edition was published in 1994. Olfson said the manual "seeks  to capture the current state of  knowledge of psychiatric disorders. Since 2000  ... there have been  important advances in our understanding of the nature of  psychiatric  disorders."

 Catherine Lord, an autism expert at Weill  Cornell Medical College in  New York who was on the psychiatric group's autism  task force, said  anyone who met criteria for Asperger's in the old manual would  be  included in the new diagnosis. One reason for the change is that some  states and school systems  don't provide services for children and adults with  Asperger's, or  provide fewer services than those given an autism diagnosis, she  said.

Autism researcher Geraldine Dawson, chief science officer for the   advocacy group Autism Speaks, said small studies have suggested the new  criteria  will be effective. But she said it will be crucial to monitor  so that children  don't lose services.

 Other changes include:


A new diagnosis for  severe recurrent temper tantrums ? disruptive  mood dysregulation disorder.  Critics say it will medicalize kids' who  have normal tantrums. Supporters say it  will address concerns about too  many kids being misdiagnosed with bipolar  disorder and treated with  powerful psychiatric drugs. Bipolar disorder involves  sharp mood swings  and affected children are sometimes very irritable or have  explosive  tantrums.
Eliminating the term "gender identity disorder." It  has been used  for children or adults who strongly believe that they were born  the  wrong gender. But many activists believe the condition isn't a disorder  and  say calling it one is stigmatizing. The term would be replaced with  "gender  dysphoria," which means emotional distress over one's gender.  Supporters equated  the change with removing homosexuality as a mental  illness in the diagnostic  manual, which happened decades ago.


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## David Baxter PhD (Dec 2, 2012)

*And the inevitable "The World Is Ending" reactions begin*

*DSM 5 Is Guide Not Bible?Ignore Its Ten Worst Changes*
by Allen J. Frances, M.D. in _Psychology Today_
December 2, 2012 

*APA approval of DSM-5 is a sad day for psychiatry.*

This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry. The Board of Trustees of the American Psychiatric Association has given its final approval to a deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound. My best advice to clinicians, to the press, and to the general public  - be skeptical and don't follow DSM 5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication. Just ignore the ten changes that make no sense.

Brief background. DSM 5 got off to a bad start and was never able to establish sure footing. Its leaders initially articulated a premature and unrealizable goal - to produce a paradigm shift in psychiatry. Excessive ambition combined with disorganized execution led inevitably to many ill conceived and risky proposals.

These were vigorously opposed. More than fifty mental health professional associations petitioned for an outside review of DSM 5 to provide an independent judgment of its supporting evidence and to evaluate the balance between its risks and benefits. Professional journals, the press, and the public also weighed in- expressing widespread astonishment about decisions that sometimes seemed not only to lack scientific support but also to defy common sense.

DSM 5 has neither been able to self correct nor willing to heed the advice of outsiders. It has instead created a mostly closed shop- circling the wagons and deaf to the repeated and widespread warnings that it would lead to massive misdiagnosis. Fortunately, some of its most egregiously risky and unsupportable proposals were eventually dropped under great external pressure (most notably 'psychosis risk', mixed anxiety/depression, internet and sex addiction, rape as a mental disorder, 'hebephilia', cumbersome personality ratings, and sharply lowered thresholds for many existing disorders). But APA stubbornly refused to sponsor any independent review and has given final approval to the ten reckless and untested ideas that are summarized below.

The history of psychiatry is littered with fad diagnoses that in retrospect did far more harm than good. Yesterday's APA approval makes it likely that DSM 5 will start a half or dozen or more new fads which will be detrimental to the misdiagnosed individuals and costly to our society.

The motives of the people working on DSM 5 have often been questioned. They have been accused of having a financial conflict of interest because some have (minimal) drug company ties and also because so many of the DSM 5 changes will enhance Pharma profits by adding to our already existing societal overdose of carelessly prescribed psychiatric medicine. But I know the people working on DSM 5 and know this charge to be both unfair and untrue. Indeed, they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies. Their's is an intellectual, not financial, conflict of interest that results from the natural tendency of highly specialized experts to over value their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM 5 to real life clinical practice (particularly in primary care where 80% of psychiatric drugs are prescribed).

The APA's deep dependence on the publishing profits generated by the DSM 5 business enterprise creates a far less pure motivation. There is an inherent and influential conflict of interest between the DSM 5 public trust and DSM 5 as a best seller. When its deadlines were consistently missed due to poor planning and disorganized implementation, APA chose quietly to cancel the DSM 5 field testing step that was meant to provide it with a badly needed opportunity for quality control. The current draft has been approved and is now being rushed prematurely to press with incomplete field testing for one reason only- so that DSM 5 publishing profits can fill the big hole in APA's projected budget and return dividends on the exorbitant cost of 25 million dollars that has been charged to DSM 5 preparation.

This is no way to prepare or to approve a diagnostic system. Psychiatric diagnosis has become too important in selecting treatments, determining eligibility for benefits and services, allocating resources, guiding legal judgments, creating stigma, and influencing personal expectations to be left in the hands of an APA that has proven itself incapable of producing a safe, sound, and widely accepted manual.

New diagnoses in psychiatry are more dangerous than new drugs because they influence whether or not millions of people are placed on drugs- often by primary care doctors after brief visits. Before their introduction, new diagnoses deserve the same level of attention to safety that we devote to new drugs. APA is not competent to do this.

So, here is my list of DSM 5's ten most potentially harmful changes. I would suggest that clinicians not follow these at all (or, at the very least, use them with extreme caution and attention to their risks); that potential patients be deeply skeptical, especially if the proposed diagnosis is being used as a rationale for prescribing medication for you or for your child; and that payers question whether some of these are suitable for reimbursement. My goal is to minimize the harm that may otherwise be done by unnecessary obedience to unwise and arbitrary DSM 5 decisions.

*1. Disruptive Mood Dysregulation Disorder*: DSM 5 will turn temper tantrums into a mental disorder- a puzzling decision based on the work of only one research group. We have no idea whatever how this untested new diagnosis will play out in real life practice settings, but my fear is that it will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children. During the past two decades, child psychiatry has already provoked three fads- a tripling of Attention Deficit Disorder, a more than twenty-times increase in Autistic Disorder, and a forty-times increase in childhood Bipolar Disorder. The field should have felt chastened by this sorry track record and should engage itself now in the crucial task of educating practitioners and the public about the difficulty of accurately diagnosing children and the risks of over- medicating them. DSM 5 should not be adding a new disorder likely to result in a new fad and even more inappropriate medication use in vulnerable children.


*2. Normal grief will become Major Depressive Disorder*, thus medicalizing and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the deep consolations of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life.

*3. The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder*, creating a huge false positive population of people who are not at special risk for dementia. Since there is no effective treatment for this 'condition' (or for dementia), the label provides absolutely no benefit (while creating great anxiety) even for those at true risk for later developing dementia. It is a dead loss for the many who will be mislabeled.

*4. DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder* leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs.

*5. Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness called Binge Eating Disorder*.

*6. The changes in the DSM 5 definition of Autism* will result in lowered rates - 10% according to estimates by the DSM 5 work group, perhaps 50% according to outside research groups. This reduction can be seen as beneficial in the sense that the diagnosis of Autism will be more accurate and specific- but advocates understandably fear a disruption in needed school services. Here the DSM 5 problem is not so much a bad decision, but the misleading promises that it will have no impact on rates of disorder or of service delivery. School services should be tied more to educational need, less to a controversial psychiatric diagnosis created for clinical (not educational) purposes and whose rate is so sensitive to small changes in definition and assessment.

*7. First time substance abusers will be lumped in definitionally in with hard core addicts* despite their very different treatment needs and prognosis and the stigma this will cause.

*8. DSM 5 has created a slippery slope by introducing the concept of Behavioral Addictions* that eventually can spread to make a mental disorder of everything we like to do a lot. Watch out for careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets.

*9. DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life*. Small changes in definition can create millions of anxious new 'patients' and expand the already widespread practice of inappropriately prescribing addicting anti-anxiety medications.

*10. DSM 5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD* in forensic settings.

DSM 5 has dropped its pretension to being a paradigm shift in psychiatric diagnosis and instead (in a dramatic 180 degree turn) now makes the equally misleading claim that it is a conservative document that will have minimal impact on the rates of psychiatric diagnosis and in the consequent provision of inappropriate treatment. This is an untenable claim that DSM 5 cannot possibly support because, for completely unfathomable reasons, it never took the simple and inexpensive step of actually studying the impact of DSM on rates in real world settings.

Except for autism, all the DSM 5 changes loosen diagnosis and threaten to turn our current diagnostic inflation into diagnostic hyperinflation. Painful experience with previous DSM's teaches that if anything in the diagnostic system can be misused and turned into a fad, it will be. Many millions of people with normal grief, gluttony, distractibility, worries, reactions to stress, the temper tantrums of childhood, the forgetting of old age, and 'behavioral addictions' will soon be mislabeled as psychiatrically sick and given inappropriate treatment.

People with real psychiatric problems that can be reliably diagnosed and effectively treated are already badly shortchanged. DSM 5 will make this worse by diverting attention and scarce resources away from the really ill and toward people with the everyday problems of life who will be harmed, not helped, when they are mislabeled as mentally ill.

Our patients deserve better, society deserves better, and the mental health professions deserve better. Caring for the mentally ill is a noble and effective profession. But we have to know our limits and stay within them.

DSM 5 violates the most sacred (and most frequently ignored) tenet in medicine- First Do No Harm! That's why this is such a sad moment.


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## Meg (Dec 27, 2012)

Geez!  I am all for standing up for patients' rights, but I'm quite offended on behalf of quite a number of my clients in relation to point five especially.  The majority of clinicians who I have come across are sensible people capable of using their clinical judgement effectively when making a diagnosis.  He's managed to insult clinicians' intelligence and a number of client populations simultaneously in his efforts to 'do no harm'.  How ironic. :facepalm:


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## Timber (Dec 28, 2012)

Are criteria for ASPD still behavior based, for example, failure to conform to social norms...? Is CD still a criterion?


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## David Baxter PhD (Dec 28, 2012)

I don't know. I haven't yet seen a copy of DSM5.


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## Timber (Dec 28, 2012)

I was hoping you noticed before they took down the changes. Actually, it looks like they made the proposed revision private instead of public because a password and ID are needed now. :/ 
Sign In


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## H011yHawkJ311yBean (Dec 29, 2012)

Good grief...  I've read articles where many people in the profession of Psychologists and Psychiatrists completely disagree with this revision.  Some of it seems pretty...  Um...  I think the most polite word that comes to my mind is "ridiculous."


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## lulu2000 (Dec 29, 2012)

Thanks for the summary. I probably won't be puchasing the hard copy!


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## GDPR (Dec 30, 2012)

All I can say is WTH? This is all so scary.


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## David Baxter PhD (Dec 30, 2012)

FWIW, I posted this article to encourage discussion but I don't necessarily agree with any of it. I would point out that psychiatrists and other mental health practitioners tend to be resistant to change and I believe that every new revision of DSM has elicited similar expressions of doom and gloom. The "hell in a handbasket" group always seems to view change as regressive rather than progressive.

Certainly, DSM-IV had many detractors when it was introduced. And it's clear that some features of DSM-IV, perhaps especially the personality disorders sections, left something to be desired.

DSM 5 may not be what everyone hoped for and certainly the repeated delays and initial secrecy were not going to encourage widespread approval of the result. But a lot of the legitimate criticism was aimed not at the final product but from proposals which were excluded from the final product. I have not yet had a chance to review the final release but at this point I think we should withhold rejection until we can see what we might be rejecting. From following the developments during the progress of the development of DSM 5, I think many of the changes afre in fact going to be improvements.


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