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Diagnostic and Statistical Manual of Mental Disorders 5

Written by Aisling Mannion on . Posted in Clinical Psychology Bite-Size

Diagnostic and Statistical Manual of Mental Disorders 5

Issue 35 – May 2013

Authors: Aisling Mannion (asiling.mannion@nottshc.nhs.uk)

Key points

  • There are increasing concerns that understandable reactions to traumatic situations are being pathologised
  • Many studies highlight a financial conflict of interest between those involved in forming diagnostic categories and the pharmaceutical industry

Implications for practice

  • Making a judgement as to an appropriate level of distress to life circumstances is a cultural and moral question, and not a scientific one
  • Rather than pathologising distress we should try to normalise it
  • We need to focus more on what has happened to people, rather than on what’s wrong with them
The Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5)1 is due to be published in May 2013. A number of changes from DSM-IV, the current version, have been made, including the addition of some new diagnostic categories and diagnostic labels. Distress, whether it be in relation to bereavement, trauma or some other stressor, is now to be diagnosed as a mental disorder. What many would perceive to be normal reactions to extremely painful and frightening experiences will soon be considered as pathological. Many have already raised concerns about the continuing medicalisation of understandable reactions to negative circumstances2.   Numerous studies have highlighted financial conflicts of interest between those involved in DSM and pharmaceutical industries involved in the production of psychiatric medication3,4. The pharmaceutical industry has sales amounting to billions of dollars, and has significant power and influence (Busfield, 2013). Busfield argues that the pharmaceutical industry has shaped mental health practice: “in the increased use of pharmaceutical treatments for mental health problems and the sidelining of alternatives; in the increased emphasis on biological understandings of mental disorder to the exclusion of other accounts; and in the widening of the boundaries of disorder so that an ever-increasing number of individuals are held to be mentally ill, and their social problems disregarded”.

New proposed diagnostic categories

Many of the diagnoses currently listed in the DSM-IV require the clinician to exclude bereavement before a diagnosis of depression is given. However, in DSM-5, a new proposed diagnosis is that of ‘Persistent complex bereavement-related disorder’. The proposed symptoms of this disorder include “intense sorrow and emotional pain in response to the death”, “feeling shocked, stunned, or emotionally numb over the loss”, and “bitterness or anger related to the loss”. The criteria state that the death must have occurred at least 12 months ago for adults, and six months for children. Imagine a child losing one, or both, of their parents: should we expect them not to feel “intense sorrow and emotional pain” after just six months? What is an appropriate level of grief? Who can judge the significance and meaning of the loss?   A new diagnostic category, including many disorders currently listed as anxiety or adjustment disorders, has been proposed. The category, ‘Trauma-and-stressor-related disorders’, includes a diagnosis of ‘trauma-or-stressor-disorder not elsewhere classified’. One of the proposed criteria for this diagnosis is “marked distress that is in excess of what would be proportionate to the stressor”. How do you define how proportionate distress is? This is surely a value judgement and not a scientifically rigorous way of assessing an individual’s mental state. Mental health services are working with increasing numbers of asylum seekers and refugees6, many of whom have experienced torture, oppression, war and family separation. Can we really expect a Western psychiatrist to be able to reliably quantify how distressed such an individual should be?   Whilst the above examples highlight areas where distress is being pathologised, some of the proposed diagnoses neglect any mention of emotional distress at all. In the proposed diagnostic category of ‘Schizophrenia spectrum and other psychotic disorders’, there has been an increase of diagnostic labels referring to psychosis from six in the current DSM-IV to 10 in DSM-5. A diagnosis of ‘Psychotic disorder not elsewhere classified’ lists a range of symptoms that an individual may display. However, unlike with other diagnostic labels, there is no need for the proposed symptoms to actually cause any level of distress to the individual. Many individuals who hear voices describe this experience as pleasant and comforting and would not see the need for treatment of any kind to eradicate their voices.

The consequences of DSM and an alternative approach

Many patients who seek psychological help often express concerns about not being ‘normal’, feeling that society pressures them to try to ‘pull themselves together’. For many mental health professionals, a big part of the job is spending time normalising experiences and helping patients to come to an understanding of their emotions and behaviours. However, this job will be made increasingly difficult if the message from the diagnostic community is that their reactions to life and their experiences are not normal, but are instead the result of some biochemical abnormality.   If an individual is struggling in life because they are distressed, what they are likely to need is someone to listen to them, to provide them with care and support, and to help them find a way through their distress which suits them. If I have lost someone I love, I want to know that it’s okay for me to feel sad, angry or numb, and that I can be helped with finding ways to cope when I’m ready. Rather than pathologising people’s understandable reactions to difficult past and current circumstances, we should look at ways to help people make sense of their experiences, and to try to regain some control and purpose in their lives. Distress is, unfortunately, a normal part of the human existence; some circumstances that cause distress are unavoidable, though many argue that the way society is structured causes unnecessary level of distress. As alternative to diagnosis Eleanor Longden7 argues that the ‘important question in psychiatry isn’t “what’s wrong with you?” but “what happened to you?”’

 REFERENCES

  1. American Psychiatric Association. (2012). Diagnostic and statistical manual of mental disorders (5th ed.): DSM-V development. Retrieved from www.dsm5.org
  2. British Psychological Society (2012). DSM-V: The future of psychiatric diagnosis: Response to the American Psychological Association. BPS: London, UK
  3. Cosgrove, L. & Krimsky, S. (2009). A comparison of DSM-IV and DSM-5 panel members’ financial associations with industry: A pernicious problem persists. PLOS Medicine, 9, 1-4
  4. Moncrieff, J., Hopker, S. & Thomas, P. (2005). Psychiatry and the pharmaceutical industry: who pays the piper?: A perspective from the Critical Psychiatry Network. Psychiatric Bulletin, 29, 84-85
  5. Busfield. J. (2013). The pharmaceutical industry and mental disorder. In S.Coles, S. Keenan & Diamond, B., Madness Contested: Power and Practice. Ross-on-Wye: PCCS Books
  6. MIND. (2012). A civilised society. Mental health provision for refugees and asylum-seekers in England and Wales. London: MIND
  7. Longden, E. (2013). Living with voices in your head – Presentation TED Talk February 2013. http://blog.ted.com/2013/02/28/living-with-voices-in-your-head-eleanor-longden-at-ted2013/
 

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