The Diagnosis of Mental Disorders

– the DSM-5 and Neuroscience –

Highlights and Controversy

Pieter Rossouw

B Honns, MClin Psych, PhD, MAPS, MCClin, QCA

Director – Unit for Neuropsychotherapy

Director – Mediros Clinical Solutions

Director – MOC Program – School of Psychology – The University of Queensland

School of Social Work and Human services – The University of Queensland

Introduction

In May 2013 the American Psychiatric Association published the long awaited Diagnostic and Statistical manual of mental Disorders (the DSM-5). This is to replace the DSM-IV-TR. This manual is based on the same principles and approach that the authors of the DSM have followed for a number of editions.  The diagnostic structure, the basic sub-divisions (chapter organization), multiaxial system and levels of functioning (GAF scales) – all remained exactly the same. In short – the concept has remained unchanged – only the recipes changed somewhat.

The arrival of the DSM-5 was met with anticipation. Many descriptors were dated and the need was often expressed for an updated version of disorders, their symptoms and variable specifics.

Changes

The DSM-5 is different to the DSM-IV-TR on many levels. The APA released a document describing the” highlights of changes from the DSM-IV-TR to the DSM-5” (APA 2013). This document can be downloaded from the APA website.  The document highlights some of the key changes:

• Neurodevelopmental disorders
  • Changes to the concept of intellectual disability – the term mental retardation is replaced with intellectual disability and intellectual developmental disorder introduced
  • Communication disorders – replaces the DSM-IV-TR’s expressive and mixed receptive-expressive language disorders
  • Autism Spectrum Disorders – replaces autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder NOS
  • Small symptom based changes were introduced to ADHD
  • Specific learning disorder combines a number of DSM-IV-TR diagnoses of reading disorders, mathematics disorder, disorder of written expression and learning disorder NOS.
  • Motor disorders which includes developmental coordination disorder, stereotype movement disorder, Tourette’s disorder, persistent motor or vocal tic disorder.

• Schizophrenia Spectrum and Other Psychiatric Disorders
  • Schizophrenia – small symptom based changes were introduced.
  • Schizophrenia subtypes (paranoid, disorganized, catatonic etc.) are eliminated due to low reliability, diagnostic stability and validity
  • Schizoaffective disorder, delusional disorder and catatonia – small symptom based criteria have been introduced.

• Bipolar and related disorders
  • There are changes to criterion A – emphasis on activity and energy and the specifier for anxious distress is “delineated” (APA 2013).

• Depressive Disorders
  • Two new depressive disorders are introduced – disruptive mood dysregulation disorder (children up to 18 years of age) and premenstrual dysphoric disorder
  • Bereavement exclusion – is now removed

• Anxiety Disorders
  • Obsessive-compulsive disorder is no longer described as an anxiety disorder and is now linked in the same category with PTSD and acute stress disorder.
  • Panic disorder and agrophobia were “unlinked” (APA 2013) and are now seen as two diagnoses.
  • In most cases of anxiety disorders – individuals over the age of 18 must experience the symptoms for at least 6 months prior to making the diagnosis.
  • Separation anxiety disorder is now recognized as an anxiety disorder as is selective mutism.

• Obsessive-Compulsive and related disorders.
  • This group is now a standalone chapter in the DSM-5 due to “increasing evidence that these disorders are related to one another” (APA 2013).
  • Small changes were introduced in OCD and Body dysmorphic disorders
  • Hoarding disorder is a new disorder in DSM-5. The APA indicates that hoarding disorder may have unique neurobiological correlates (APA 2013).

• Trauma and Stressor-Related disorders
  • This standalone group was subject to “significant” symptom related changes.  Criterion A for PTSD is more explicit in regards to how an individual experienced traumatic events with some smaller changes to the rest of the symptom clusters (APA 2013).
  • The two subtypes of reactive attachment disorder – emotionally withdrawn/inhibited and indiscriminately social/disinhibited are now defined as separate disorders (APA 2013).

• Dissociative Disorders
  • Depersonalization disorder is now called depersonalization/derealisation disorder and some minor criteria changes introduced.
  • Criterion A of dissociative identity disorder has been expanded to include “functional neurological symptoms” – (affect, behavior, consciousness, memory, perception, cognition and sensory/motor functioning).

• Somatic Symptom and Related Disorders
  • The “somatoform disorders” are now called “somatic symptom and related disorders”. This group is/was even more controversial than other groups in the DSM system due to many “unexplained” effects/symptoms of medications. An interesting subgroup “medically unexplained symptoms” has been introduced. The DSM-5 states “DSM-IV criteria overemphasized the importance of an absence of medical explanation for the somatic symptoms…the reliability of medically unexplained symptoms is limited…the DSM-5 classification defines disorders on the basis of positive symptoms” (APA 2013). The growing concerns and indicators in research in relation to the effect- and side effect profiles of medications are not just NOT addressed, but given even less prominence than in the DSM-IV.
  • Hypochondriasis has been dropped as disorder
  • Small changes have been introduced in relation to pain disorder.

• Feeding  and eating disorders
  • No major changes were made in this group – some clarifications of descriptors (pica, bulimia nervosa, binge-eating disorder) were introduced.

• Sleep-wake disorders
  • This classification group includes 10 disorder groups and the sleep disorders related to mental disorders or general medical conditions have been removed.

• Sexual Dysfunctions
  •  To restrict “over diagnosing” (APA 2013), the duration has been extended to 6 months and more precise severity criteria.
  • Genito-pelvic pain/penetration disorder is a new introduction to the DSM
  • Sexual aversion disorder has been removed from the DSM
  • Gender dysphoria is a new diagnosis focusing on “gender incongruence” and replaces the “sexual and gender identity disorder”.

• Disruptive, Impulse-Control and Conduct Disorders
  •  This group is new to DSM. It is a combination of childhood and adolescence and impulse-control disorders.
  • ADHD is not listed in this category but as neurodevelopmental disorder.

• Substance-Related and Addictive Disorders
  • This group is expanded and now also includes gambling disorder (there is even brief mentioning of the activation of the brain’s reward system).

• Neurocognitive Disorders
  • Small changes to descriptors of neurodegenerative disorders (Alzheimer’s, Pick’s, Parkinson’s,  Creutzfeldt-Jacob, Huntington’s) are introduced.

• Personality Disorders    
  • Although the authors of DSM-5 suggested that an alternative approach to the diagnosis of personality disorders was developed (APA 2013), the result is a system that is virtually unchanged in terms of classification, description and symptoms of the various personality disorders.

• Medication-induced Movement Disorders and Other Adverse Effects of Medication
  • The term “neuroleptic” medication is replaced with “anti-psychotic” medication however the term “neuroleptic” is upheld in the descriptors in relation to this group of disorders. This group with adverse effect profiles as result of intake of medication to treated clinical syndromes and conditions. “Treatment” consists basically of medication reduction or discontinuation.
  • Antidepressant discontinuation syndrome is the only subgroup that relates to medication used to treat depression/anxiety/related disorders. Treatment suggested is to “restart the medication” that has been discontinued or take another medication that has a similar action (APA 2013).
  • There are no subgroups for disorders related to the introduction of antidepressant medications.
  • There are no subgroups for disorders related to the introduction of antipsychotic medications.
  • There are no subgroups for disorders related to the introduction of benzodiazepine medications

• Other Conditions that may be a focus of Clinical Attention
  • DSM-5 also identified conditions that are not associated with mental disorders but of clinical significance. This extensive section focuses on:
  • Relational problems – problems related to family upbringing and primary support group;
  • Abuse and neglect – child physical abuse, child sexual abuse, child neglect, child neglect (suspected), child psychological abuse;
  • Adult maltreatment and neglect – spouse or partner violence (physical or sexual), spouse or partner neglect, spouse or partner abuse (psychological), adult abuse by nonspouse or nonpartner;
  • Educational and occupational problems;
  • Housing and economic problems;
  • Other problems related to the social environment (living alone, acculturation, social exclusion, rejection, discrimination);
  • Problems related to crime interaction with the legal system (victims of crime, conviction in civil or criminal proceedings without imprisonment, imprisonment, problems related to release from prison, problems with legal circumstances);
  • Other health encounters (sex counselling);
  • Problems related to other psychological, personal and environmental circumstances (religious of spiritual problems, unwanted pregnancy, multiparity, discord with social service provider, victim of terrorism or torture;
  • Other circumstances of personal history (personal history of self-harm, military deployment, lifestyle, child or adolescent or adult anti-social behaviour, unavailability of medical services, nonadherence to medical treatment, overweight or obesity, malingering, wandering, borderline intellectual functioning (APA 2013).

Comments

The publication of the DSM-5 is a significant achievement. It is the result of countless consultations and deliberations on many levels – the American Psychiatric Society stakeholders, academics, practitioners and many lobby groups for specific organisations. This needs to be acknowledged and applauded. Many changes were made to the DSM-IV-TR version and many additions made. The focus is still on creating a manual that provides a “common language” to describe psychopathology. It creates a set of labels and tries to clearly define each of them. As is the case with previous DSMs the strength of this version is its reliability – the ability to ensure that all its users use the same terms in the same way. As is the case with previous versions its weakness is its lack of validity. The DSM system bases its “validity” on consensus by its groups rather than clinical research data. This is an archaic approach which is flawed in its core (when the majority decide the horse is black, then it must be a black horse). Further, the total absence of research based outcomes in neurobiological data, in order to understand the presentations of mental disorders, is, to say the least – alarming.

It is not surprising that, just prior to the release of the DSM-5, the National Institute of Mental Health (NIMH – the world’s largest funding agency for research into mental health) (strongly) withdrew its support from the manual. The director of the Institute, Thomas Insel indicated that the Institute will no longer fund any research projects that rely on DSM criteria and that the institute will be “re-orienting its research away from DSM categories”  (NIMH 2013).

This is a major blow for a manual that, according to the NIMH only offers “fumbles and errors” and states: “symptom-based diagnosis once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment” (NIMH 2013).

The NIMH suggests an approach based on the following assumptions:

• A diagnostic approach based on the biology as well as symptoms must not be constrained by the current DSM categories
• Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion and behaviour
• Each level of analysis needs to be understood across a dimension of function
• Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment (NIMH 2013).

Although the NIMH leaves some room for the role of the environment (nature) – it seems this aspect plays a relatively small role. This criticism reflects a significant lack of focus in a significant work that epigenetic studies clearly show and indicates a focus on a specific agenda that seems to be more exclusive than inclusive.

Current interpersonal neurobiology studies and research focuses on a holistic inclusive approach to understand mental disorders – a focus on genetics (the history of risk and resilience), early (and late) life experiences (the interplay that establishes neural patterns of behaviour), current presentation (symptomatology) and facilitation of new neural patterns by engaging in a therapeutic relationship (right brain to right brain communication), an  enriched environment and neural rewiring (ongoing activation) to reduce symptoms, facilitate new behaviours, ensure effective duration (new neural pathways) and enhance quality of life.

The question is whether the DSM-5 will contribute to these outcomes or hinder them?

References

American Psychiatric Association, (2013). The Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. DSM-5. Washington, American Psychiatric Association.

National Institute of Mental Health – http://www.nimh.nih.gov

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