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See Inside Scientific American Mind Volume 23, Issue 2

Psychiatry's "Bible" Gets an Overhaul [Preview]

Psychiatry's diagnostic guidebook gets its first major update in 30 years. The changes may surprise you

Therefore, psychiatrists cannot ignore the new manual and go about business as usual. They must adapt, especially if they want to be sure that their patients keep receiving affordable treatment. Yet this diagnostic bible is a work in progress. In fact, although the revisions are 90 percent complete, the APA may still make significant changes and even delay the book’s official release. Even after its publication, the DSM will remain a snapshot of a field in flux—an ambitious attempt to capture an evolving, often ambiguous science.

Diagnosing the DSM
Psychiatrists have been kicking around the DSM-5 in a scientific scrimmage that dates back to 1999, when the APA and the NIMH sponsored a meeting to jump-start planning. More than 13 joint conferences later, committees of psychiatrists and psychologists have churned out dozens of white papers outlining how best to overhaul psychiatry’s bible. In April 2006 the APA appointed clinical psychologist David Kupfer and Regier as chair and vice chair, respectively, of a team of 27 scientists assigned to digest the research literature and propose revisions to this historic volume.

Right away researchers fingered several major failings of the DSM-IV. First, many of the symptom checklists were so similar that many patients left a psychiatrist’s office with several official diagnoses rather than just one. It is unlikely that large numbers of patients each have a variety of different disorders, says Steven Hyman, a task force member. Rather, he suggests, a single cognitive or biological process—maladaptive thought patterns, for instance, or atypical brain development—may manifest itself in symptoms of more than one ailment. To address this problem, curators of the new book eliminated over a dozen less distinct disorders, in some cases merging them into larger categories of illness, such as the autism spectrum [see “Psychosis Revisited”].

Patients and their psychiatrists often struggle with the opposite problem, too: a person’s symptoms might be fewer or milder than those listed in the DSM or simply do not match any disorder in the manual. As a result, psychiatrists slap large factions of their clientele with a “disorder not otherwise specified” label. The most frequently diagnosed eating disorder is “eating disorders not otherwise specified.” The predominant autism spectrum disorder? By most estimates it is “pervasive developmental disorder not otherwise specified.” The third most common personality disorder is, you guessed it, “personality disorder not otherwise specified.” Health professionals rely so heavily on catchall diagnoses because the current DSM has some serious gaps in its diagnostic offerings and has some superfluous entries.

In addition to eliminating ailments, the DSM-5 will encourage psychiatrists to collect more detailed information about patients’ symptoms. With more data to consider and more complete descriptions in the manual, the theory goes, psychiatrists are more likely to find a proper match between a patient and an illness.

Degrees of Dysfunction
To improve diagnoses, the DSM-5 asks doctors to grade the severity of their clients’ symptoms. A verdict of major depression, for example, will include a rating for each symptom—insomnia, say, or thoughts of suicide. Similarly, a child who is diagnosed with attention-deficit hyperactivity disorder would also receive an assessment of her ability to focus, ranging from poor to excellent.

This ideological shift signals a step away from the simplistic notion that mental illnesses are discrete conditions wholly distinct from a healthy state of mind. Instead the new volume reflects the idea that everyone falls on a spectrum that stretches from typical behavior to various shades of dysfunction. Where you land on that scale determines whether your symptoms merit treatment. This approach might assist, for example, psychiatrists evaluating a patient’s attention problems, which can seem almost ubiquitous in younger children. Considering an individual in the context of others can make it easier to flag the neediest cases. Psychiatrists, of course, already use many scales and questionnaires in their practice. The DSM-5 will standardize such ratings so that doctors use the same scales to measure a given disorder and increase the chances they will reach similar conclusions about comparable patients.

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