Two Psychiatrists Discuss the Changes (and Controversies) of DSM-5

At childmind.org we’ve had our heads bent over the DSM-5 this week, chasing down the changes we’ve been expecting in diagnoses that affect children.

The new piece is a very incisive conversation between Drs. Bennett Leventhal and David Shaffer, two eminent child and adolescent psychiatrists, that took place Friday for Speak Up for Kids. The doctors discussed the updates on diagnostic thinking included in the DSM-5, and the widely publicized charge that the DSM itself is invalid because it is based on clinical observation and studies, rather than on brain research. You know, the quip about how the brain didn’t read the DSM.

Dr. Shaffer sums up the history of the DSM, from its prewar origins in an effort by the Department of Defense to categorize the mental disorders suffered by veterans of the Armed Forces, to an effort to standardize what had been rough classifications into more and more precise descriptions. The gradual iteration of DSM criteria (this many symptoms, over this period of time, with this effect on functioning) was done, he notes, not to pathologize more behavior but to make it possible for researchers to be able to effectively identify subjects for their studies and, not incidentally, to make diagnosis something that many different professionals could do.

Changes in the DSM are made, he says, when new information calls into question the validity of criteria and their effectiveness in clinical setting. One example is the important new diagnosis disruptive mood disregulation disorder. It’s a response to what Dr. Shaffer describes as a real crisis in child psychiatry—an escalating number of kids being given the diagnosis of bipolar disorder when they don’t meet the criteria applied to older-onset bipolar disorder: episodes of mania. These kids are chronically irritable and prone to meltdowns, and their need for help is urgent. But they don’t follow the typical course of bipolar disorder into adulthood, and the medications used to fight bipolar disorder don’t work well for these children. Bipolar disorder is a very serious, lifelong diagnosis to give to parents, especially, he notes, “when the evidence was so weak.”

Creating a new diagnosis, he says, is the first step to studying and rethinking approaches to helping these children. Rather than developing adult bipolar disorder, many of them develop anxiety disorders as they get older. It may be more fruitful, he hypothesizes, to think of them as very anxious children. Children with early-onset anxiety fight very hard to control their environments in order to manage anxiety and feel safe; the smallest change in plans or deviation from their expectations can make them melt down. Instead of treating them with antipsychotics, it makes sense to treat them with antidepressants and other medications that are effective for anxiety. And it could change the therapeutic approach, as well—to exploring and treating the anxiety, if that’s what’s making them very upset and very aggressive, with behavioral therapy.

Drs. Shaffer and Leventhal go through the other big changes in DSM-5 as well. They offer some interesting thoughts about the controversies that have surrounded the changes.

Specific changes, Dr. Shaffer notes, are always debated fiercely within the mental health community, with some advocating against the updates. He argues that some of the many professionals who lobby against changes in the DSM have a vested interest in seeing the criteria remain the same—books, rating scales, research projects all face updating or rethinking when the DSM changes. Some worry about schools and the insurance companies—whether they will accept the changes, rather than whether they will allow professionals to do a better job understanding and helping kids. Just something to keep in mind.

To the charge that psychiatrists are bent on medicalizing more and more of human behavior, he notes that half of the members of the committees who worked on the updates for DSM-5 are professionals other than psychiatrists. He also notes that no one is allowed on the working committees who has pharmaceutical ties or is receiving pharma research funding.

Both doctors noted that the prevalence of mental illness isn’t likely to change, but the updates may bring some different symptoms into the discussion of a disorder, and hence “make people who use it more sensitive to certain symptoms.” If your child’s diagnosis has changed, do you need to get a new diagnosis? That depends, Dr. Shaffer said, on two things: “Has the diagnosis been useful? Has it led to effective treatment?” If the answer to those questions is yes, he said, don’t worry about DSM-5. Your current diagnosis will be grandfathered in. If treatment is not working, you might want to see your clinician about how the changes affect your child.

And to the charge that the DSM is a “philistine endeavor” because it isn’t based on brain science, I think it’s safe to say that both doctors look forward to advances in brain science that will yield treatment applications, but at this point those applications are few, and the DSM is an enormously valuable tool for identifying, investigating, and treating mental illness.