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What the DSM is All About
Whether you’re familiar with the Diagnostic and Statistical Manual of Mental Disorders or have only a vague clue this “bible” of psychiatry exists, a revised version known as the DSM-5 is slated for its official release in May 2013. Controversy surrounding the changes has been swirling throughout the 14-year revision process as any change to the DSM can impact anxious children and numerous other individuals suffering from mental health issues.
It can mean the difference between being eligible to receive treatment and services — or not.
The changes can affect whether or not our insurance plans cover treatment or the type of treatment we or our anxious kids may receive based on the diagnosis, or “label,” assigned to us from the manual.
Although the DSM does not outline how anxiety in children or other specific conditions should be treated, it does outline what counts as an official disorder and how the disorder is classified. Classifications and definitions of mental health disorders play a huge part when it comes to insurance coverage as well as qualifications for treatment and services offered by mental health professionals, schools and other agencies.
In other words, if you or your child’s mental health issue no longer has a valid label as per the DSM or your symptoms no longer meet the specifically defined criteria, you may no longer be eligible for treatments and coverage.
Revisions to the DSM are also few and far between, another reason for all the hoopla. Since its debut in 1952, the manual has only seen four revisions over a six-decade period. The preceding set of revisions prior to the DSM-5 came with the DSM-IV in 1994.
The Revision Process
Although the changes can potentially affect thousands if not millions of children with anxiety and people with any
psychological issue across the board, the core group in charge of making the latest round of changes had a scant 27 members. Known as the DSM-5 Task Force, the group members “collectively represent research scientists from psychiatry and other disciplines, clinical care providers, and consumer and family advocates,” according to the American Psychiatric Association (APA).
Members of this core group of 27 must disclose any relationships they had with the mental health industry prior to their appointment to the task force in the three years leading up to their nomination (19 of them did). They must also swear not to take in more than $10,000 from industry sources every year they are active on the task force, which was officially formed in 2007. This is done to try and ensure that no member is being “bribed” by pharmaceutical companies to particularly favor a diagnosis that the company thinks could be treated with medication they manufacture.
Although the task force was formed in 2007, proposed revisions to the DSM-IV started popping up about five years after its 1994 publication. Input from hundreds of mental health professionals created numerous suggestions which were then reviewed by work groups. The groups reviewed what was working well in the DSM-IV and what changes they thought could help mental health service providers. The APA said four principles were guiding the current revision process:
“First, the highest priority is clinical utility – that is, making sure the manual is useful to those who diagnose and treat patients with mental illness, and to the patients being treated. Second, all recommendations should be guided by research evidence. Third, whenever possible, DSM-5 should maintain continuity with previous editions. And fourth, no a priori restraints should be placed on the level of change permitted between DSM-IV and DSM-5.”
The APA also noted task force members had to consider the impact changes in the manual would have on clinical practice, the prevalence of a particular disorder and “other important factors” while also keeping in mind the advances that could be made with revisions and updates to the diagnoses.
Advances in genetics, neurology and behavioral sciences over the past 20 years are in large part what prompted the need for revisions, the APA said. Such advances add to the understanding of mental illness and the DSM-5 intends to reflect that new understanding.
An initial draft of the DSM-5 was made public in 2010 and further revisions were made after mental health clinicians, advocates and researchers piped in with some 13,000 comments, Forbes reports.
“At every step of development, we have worked to make the process as open and inclusive as possible. The level of transparency we have strived for is not seen in any other area of medicine,” said James H. Scully, MD, medical director and CEO of the APA.
So why are some folks still in such a tizzy? Because any change to this standard handbook can mean a change in the coverage and services available. Checking out the specific changes, especially those that may affect children struggling with anxiety, can help put everything in perspective.
What the DSM Changes Are – The Plain English Guide
Overall format and structure
Roman numerals bit the dust to better fit technology: goodbye DSM-IV, hello DSM-5. The chapters were re-ordered into three distinct sections. Section 1 tells you how to use the manual and explains the changes. Section 2 lists the revised included disorders. Section 3 includes conditions that have not yet made the cut but need more research before being named a “formal disorder.” Section 3 also includes the glossary, key players in the DSM-5’s development and other info.
Changes in the DSM-5 put it more in sync with another widely used manual, the World Health Organization’s International Classification of Diseases, eleventh edition (ICD-11), PsychCentral reports. This may enhance communication and consistency among mental health care professionals who use either handbook.
Although some disorders were eliminated, some added, and others shifted into definitions of similar conditions, the overall number of disorders remains about the same. In addition to a definition of each disorder, the DSM-5 added examples to each disorder, something the DSM-IV and other versions were lacking.
Section 2, which lists all the formal disorders, will now include the following:
- Autism spectrum disorder: New development. The new umbrella term of Autism Spectrum Disorder (ASD) is an expansive definition that covers everything from autism disorder, aka ‘classic’ autism, to the less severe Asperger’s Disorder. The ASD category includes the diagnosis of Childhood Disintegrative Disorder and PDD-NOS, or Pervasive Developmental Disorder – Not Otherwise Specified. This may be the change that hits home with your anxious child, although the change may not necessarily be detrimental.
- Binge Eating Disorder: New addition as own category!
- Disruptive Mood Dysregulation Disorder: New addition as own category! If your anxious child throws three or more temper tantrums per week over a one-year period, you may have a case for Disruptive Mood Dysregulation Disorder.
- Excoriation (skin-picking) Disorder: New addition as own category!
- Hoarding Disorder: New addition as own category!
- Pedophilic Disorder: Same disorder but renamed from “pedohilia.”
- Personality Disorders: New development. Ten categories were reduced to six specific personality disorder types. Several conditions of each type must be met before diagnosis can go through. The six types are: Antisocial, Avoidant, Borderline, Narcissistic, Obsessive/Compulsive and Schizotypal.
- Posttraumatic Stress Disorder: New development, now part of new chapter on “Trauma- and Stressor-Related Disorders”
- Removal of bereavement exclusion: New development as bereavement, or loss of a loved one, previously did not count as an official disorder under the depression category. Now it does.
- Specific Learning Disorders
- Substance Use Disorder: New name that combines substance abuse and substance dependence into a single disorder.
Section 3, which lists disorders that have yet to qualify as a formal disorder, will now include the following:
- Attenuated Psychosis Syndrome
- Internet use Gaming Disorder
- Non-suicidal self-injury
- Suicidal Behavioral Disorder
Out! Disorders that didn’t make the cut for either Sections 2 or 3 consist of the following:
- Anxious Depression
- Hypersexual Disorder
- Parental Alienation Syndrome
- Sensory Processing Disorder
The Controversy and Ongoing Criticism
Some of the loudest controversy erupting from the DSM-5 is the change to the autism category. The definition is much broader and inclusive than in the past and some fear what broader impacts that may have. Because Asperger’s Disorder is a mild form of autism, Forbes says controversy may be erupting over lumping it under the broad ASD. Asperger’s Disorder is typically marked by social interaction issues and unusual behaviors or interests but not by problems with intellectual or language abilities. Your anxious child who was once labeled as having Asperger’s would now carry the label of ASD under the DSM-5.
“Some people with Asperger’s might not identify with the more wide-ranging ‘Autism’ label,” Forbes says. It is unclear if the identification issue stems from treatment concerns or is a point of pride.
Concerns noted at NPR’s Shots blog are regarding the child who has behavioral problems but may no longer fit into a diagnosis in the revised manual. “He or she may not only not be offered services or therapies,” Forbes points out, “but they may just be labeled ‘trouble,’ and actually punished for the behavior.” This, too, could be a huge factor for anxious children who do no longer fit a specific diagnosis.
Other concerns reported by CNN are from a clinical standpoint. Doctors are arguing that the expanded ASD definition will lead to an increase – or decrease – in children diagnosed with ASD, depending on whom you ask. Doctors are also voicing concern about guidelines for diagnosis and if the APA is expecting them to be retroactive.
“We have people waiting months for an autism diagnosis,” Dr. Bryan King told CNN. “There’s no way and no place for clogging the diagnostic wait lists for people to get rediagnosed for administrative purposes.” King also said those already diagnosed under the former definition will not lose their autism diagnosis.
The newly included Disruptive Mood Dysregulation Disorder (DMDD) has sparked controversy in the past, Forbes says. The concern was the official inclusion of the disorder could result in a diagnosis in children who are big on throwing tantrums but not necessarily suffering from a “disorder.” On the flip side, the specific disorder of DMDD was included to cut down on the catch-all Bipolar Disorder in children, a diagnosis that often results in the use of antipsychotics. Children with anxiety may be particularly prone to temper tantrums and DMDD may be something to watch for during a diagnosis.
Protests by the American Psychological Association have also responded to the changes, Forbes says, but not necessarily those regarding ASD. The group “has argued that some of the changes have unnecessarily ‘medicalized’ normal human mental processes.”
And then there’s the “hoarding” and “skin picking” additions that brought on criticisms of “diagnosis creep,” or the expansion of a particular trait of a disorder into its own category. Hoarding, for example, was formerly housed under the diagnosis of Obsessive/Compulsive Disorder. One may wonder if reality TV has any bearing on what counts as an official mental disorder.
All in Favor
Perhaps not surprisingly, members of the DSM-5 Task Force say the changes are terrific, even those surrounding ASD.
“I’m feeling quite good about the series of recommendations that were made in that area,” task force chair Dr. David J. Kupfer told CNN. “It will help us diagnose these children in a more consistent way.” He added that the new research that led to the new definitions and changes will give experts a deeper understanding of social disorders, communicative disorders, repetitive behaviors and other issues that may be linked to child anxiety.
Autism expert Catherine Lord, who doubled as a member of the autism task force, quelled fears that Asperger’s diagnoses would be left out in the cold. She told the Huffington Post that those who met Asperger’s criteria in the DSM-IV will be covered by the DSM-5’s ASD definition.
She quelled fears even further when she noted that various school systems and state agencies don’t offer any services or at least as many services for adults and children with Asperger’s as they do for those diagnosed with autism.
A few voices from the public, specifically parents with children diagnosed with Autism, didn’t have a problem with the revised definition. Mother-of-four Kelli Gibson, who has four sons with varying forms of autism, told the Huffington Post she was happy about the changes. Each son had a different label under the DSM-IV, including one with Asperger’s Disorder, but now they’ll all share the same diagnosis of ASD.
“To give it separate names never made sense to me,” Gibson told the Post.”To me, my children all had autism.”
Despite the speculations, the full impact of the DSM-5 on you and your anxious child remains to be seen. Arming yourself with the facts is a very good first step so you’re not consumed by the hoopla or unnecessary fears. The DSM-5 makes its official debut at the regular meeting of the APA scheduled for May in San Francisco. Stay tuned!
Additional DSM-5 News and Updates
DSM-5 Danger: What Happens When Your Child’s ‘Normal’ Grief becomes Clinical Depression
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