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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

These detailed assessments should allow treatments to become more tailored. For example, a patient with mild signs of depression is more likely to benefit from therapy and lifestyle changes than from antidepressant medication, which recent findings suggest is more
effective for severe depression. Psychiatrists and patients will also gain a new way to track improvement. A shift in the depression gauge from “severe” to “moderate” may in itself lift a patient’s spirits, motivating him to stick to the regimen propelling his progress.

Although most psychiatrists support the idea of measuring severity, practitioners have also voiced various concerns. Placing several previously distinct disorders under the umbrella of autism, for example, has ignited fears that autistic people with less severe symptoms will no longer qualify for a diagnosis or treatment. Questions have also been raised about how insurance companies will respond: Could these scales create barriers to treatment? A simple diagnosis of depression may no longer be enough to qualify a patient for anti­depressants—insurance companies may demand that a patient’s depression meet a certain severity level.

The new procedures will require patients to complete more evaluations and surveys than ever before, culminating in larger amounts of paperwork and more time spent on every diagnosis. Some psychiatrists worry the extra effort will deter their peers from using the DSM properly—and a few have even proposed doing away with the severity ratings altogether. More broadly, psychiatrists have also objected to the addition of certain disorders that they consider dubious.

A Primitive Guide?
A second sweeping change to the DSM is the way it clusters disorders. The DSM-IV was organized around three categories of illness. One group captured all major clinical disorders, such as depression, bipolar disorder and schizophrenia. Another section encompassed all personality and developmental disorders. The third category contained “medical” problems that might play a role in mental illness: diabetes or hypothyroidism, for instance, can exacerbate depression. The DSM-5 throws these relatively arbitrary divisions out the window. Instead it arranges diseases chronologically, starting with illnesses that psychiatrists typically diagnose in infancy or childhood—such as neurodevelopmental disorders—and moving toward those frequently found in adults, such as sexual dysfunctions. When evaluating a toddler, for instance, a psychiatrist can focus on the front of the DSM-5 or the beginning of a chapter, say, on depressive disorders, where he or she will find the types of depression most likely to afflict children.

As genetic and neuroimaging studies improve our understanding of the relations among ailments, the DSM will be able to swiftly adapt. The APA plans to publish the new manual in print and as a “living” electronic document that can be updated frequently as version 5.1, 5.2, and so on. (The APA dispensed with Roman numerals to make this labeling practical.)

Eventually researchers aim to root the DSM in the biology of the brain. Someday scientists hope to find useful “biomarkers” of mental illness—genes, proteins or patterns of electrical activity in the brain that can serve as unique signatures of psychiatric problems. Lab tests based on such markers would make diagnosing mental illness easier, faster and more precise.

“The DSM has always been a primitive field guide to the world of psychological stress because we know very little about the underlying neural chemistry of psychological symptoms,” says psychiatrist Daniel Carlat of the Tufts University School of Medicine. “But over the past 60 or 70 years the categories have become more reliable and meaningful.” No one argues that the DSM flawlessly mirrors mental illness as people experience it, but every revision sharpens the reflection—and with it, people’s understanding of themselves. 

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