Normal or Not? New Psychiatric Manual Stirs Controversy

With the release of the latest edition of the mental health manual, the Diagnostic and Statistical Manual of Mental Disorders (DSM), LiveScience takes a close look at some of the disorders it defines. This 10-part series asks the fundamental question: What is normal, and what is not?

As of May 22, many mental disorders will never be the same. The full nature of the changes — some quite controversial —will become apparent with the publication of the latest edition of the mental health manual that classifies these disorders.

This guidebook, the Diagnostic and Statistical Manual of Mental Disorders (DSM), is an influential document. By setting forth the criteria used to diagnose disorders, it draws the line between what is normal and what is not. This diagnostic line can have many implications for people’s lives; for instance, a diagnosis based on its criteria can determine whether or not someone qualifies for special education services or disability benefits.

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The high stakes, in combination with the complexity and mysteries of the human mind, makes revising this manual a challenging project, to say the least, and likely to generate heated controversy, which it has. [The 10 Most Controversial Psychiatric Disorders]

Keeping up with the times

Work on the latest edition, the fifth, began in 1999. Among the host of changes the new DSM-5 contains, some have sparked considerable discussion before its release at the annual American Psychiatric Association (APA) meeting Saturday (May 18) and subsequent official releaseon May 22.

First published in 1952, the DSM has periodically been reviewed and updated by the APA, with the last major revision completed about 20 years ago.

"Since that time, there has been a wealth of new research about mental disorders," David Kupfer, chairman of the DSM-5 task force and a professor of psychiatry at the University of Pittsburgh School of Medicine, told LiveScience in an email. "Many of the changes in DSM-5 were made to better characterize symptoms and behaviors of groups of people who are currently seeking clinical help but are not well defined by DSM-IV," Kupfer said, referring to the predecessor to DSM-5.

Psychiatric controversies

Before its publication, word of changes in the DSM-5 attracted no shortage of critics.

Among the flashpoints: Asperger's disorder will be folded into autism spectrum disorder; grief will no longer exempt someone from a diagnosis of depression; irritable children who throw frequent temper tantrums can be diagnosed with disruptive mood dysregulation disorder. [Hypersex to Hoarding: 7 New Psychological Disorders]

One prominent critic has been Allen Frances, a professor emeritus of psychiatry at Duke University who chaired the DSM-IV task force.

Frances charges that through a combination of new disorders and lowered thresholds, the DSM-5 is expanding the boundaries of psychiatry to encompass many whom he describes as the "worried well."

Diagnostic inflation?

The problem is that the manual has become too important; the diagnostic criteria carry too much responsibility, creating enormous pressure for expansion, Frances argues. For instance, a diagnosis of autism, or some other disorder, can entitle a student to special services. As a result, there is tremendous pressure to diagnose vague cases, Frances said.

News that the DSM-5 would fold Asperger's disorder into autism spectrum disorders has raised concerns from families and advocates that some people might lose their diagnosis, and as a result, services.

"My contention is this system, without anyone really noticing it, has gotten out of control and it is diagnosing many of the worried well," he told LiveScience, adding that as a result, these new patients are prescribed drugs that have the potential to cause harm. 

The architects of the DSM-5 have disputed charges such as Frances'. In a Medscape Psychiatry article published in June, Kupfer called charges that changes in the DSM-5 will lead to more people being diagnosed with mental disorders as "patently wrong."

"We sought to be conservative in our approach to revising DSM-5. Our work was aimed at more accurately defining mental disorders that have a real impact on people's lives," Kupfer told LiveScience in an email, adding that based on field trials and analyses of the changes, the task force does not expect to see more people receiving diagnoses.

He noted that DSM-5 includes approximately the same number of disorders as DSM-IV. (While some new disorders have been added, some have been combined or eliminated. Critics argue the additions will increase the diagnosis of disorders more than the other changes will decrease it.)

Setting the threshold

More than 46 percent of the U.S. population will meet the criteria for at least one DSM-IV diagnosis during their lifetimes, according to research by Ronald Kessler, a professor of health care policy at Harvard Medical School, and colleague Philip Wang published in 2008 in the Annual Review of Public Health.

When told this rate seemed high, Kessler said, "Here's something even more shocking: 99.9 percent of the U.S. population has had a physical health problem in their lives. …There are all kinds of stuff that count as physical illness. That doesn't mean you're at death's door." (Kessler was not involved in the revisions to the DSM.)

The heaviest burden of mental illness falls on a small proportion of the U.S. population —about 6 percent of people in a given year —whose mental illnesses, such as schizophrenia or major depression, impairs them to the point that they can't hold down a job, become suicidal or become socially isolated, for example, according to other research Kessler has published in the Archives of General Psychiatry in 2003.

Milder, less debilitating cases are more common; however, even these cases are associated with an increased risk of long-term problems compared with people with no diagnosis at all, Kessler and colleagues write in a 2003 paper that argues against the elimination of mild cases from the DSM.

Establishing psychiatric diagnoses is challenging because they rely on symptoms. "It's not like you can look under a microscope," Kessler said.

So, setting a threshold for a diagnosis can be somewhat arbitrary.

"At a certain point, you can say everybody’s sick," he said. "The question is, where do you draw the line."

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