Brain Science Upstages DSM-V, So-Called Mental Health 'Bible'

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Since the 1970s, the Diagnostic and Statistical Manual of Mental Disorders, has reigned as the so-called "bible" of psychiatry. But now, with the May 22 release of its fifth edition, the DSM-5 is losing some of the support of its faithful.

For the first time, the National Institutes of Mental Health, the world's largest mental health research institute, has shifted its funding support away from the DSM, citing a "lack of validity" and diagnoses based on "clusters of clinical symptoms, not any objective laboratory measure."

The DSM-5 includes a plethora of new diagnoses, some of which have been contentious: It removes Asperger's syndrome from a larger umbrella of autism spectrum disorders and creates new conditions like social anxiety disorder and somatic symptom disorder, which critics say could label patients who are physically sick as mentally ill.

"Patients with mental disorders deserve better," NIMH Director Dr. Thomas R. Insel said in a recent statement

Instead, NIMH will put more of its research dollars into a new classification system, the Research Domain Criteria (RDoC), to incorporate genetics, imaging and cognitive science that focus more on neurological systems than just a collection of symptoms.

According to Insel, the overriding premise of the 18 months of work developing the RDoC is that the brain is the "alleged seat and cause of psychiatric suffering."

RDoC would classify psychopathology based on observable behavior and neurobiological measures.

The shift comes after President Obama proposed the BRAIN Initiative, a $100 million brain-mapping project designed to promote American innovation and job growth while finding ways to treat and cure diseases such as Alzheimer's and brain damage from strokes.

The RDoC assumes that mental disorders are "biological disorders involving brain circuits that implicate specific domains of cognition, emotion or behavior. It's aim in mapping these circuits is to yield "better targets for treatment," according to Insel.

But Dr. David Kupfer of University of Pittsburgh, chairman of the American Psychiatric Association's (APA) DSM-5 task force, responded to Insel's blog post, saying that the decades-long search for biomarkers associated with mental illness remains, "disappointingly distant. ... We're still waiting."

The DSM revisions are the first in 20 years, a "generation" for clinicians, patients and their families, he said. Numerous conditions have been renamed or recategorized and the 1,000-page manual is now electronic version with references and hyperlinks.

"It is important to understand that it is only a guidebook to help clinicians diagnose behaviors and symptoms, not a treatment guide or research manual," said Kupfer. "I think we need to put that in perspective. ... It's not what many people call the Bible or the 10 Commandments."

The DSM-5 task force included 160 experts from around the world, as well as 400 research advisors. The book went public three times for input on language.

"We are very proud of that," said Kupfer.

Disorders are framed in context of age, gender and cultural expectations.

The revised manual also looks at "commonalities" that may exist between conditions like bipolar disorder, psychosis and schizophrenia, as "clues to early intervention," said Kupfer.

"We laid disorder chapters next to each other so, going forward, we might find genetic or cognitive neuroscience," he said.

The manual also tries to do more to measure the severity of certain disorders.

"We know that in clinical depression, for example, one size does not fit all," he said.

Psychology Today called the funding cuts to DSM-5 research in favor of RDoC, a "humiliating blow to the APA."

But Dr. Bruce Cuthbert, coordinator of the RDoC project and director of the division of adult transitional research at NIMH, said research will continue in both camps.

"Science is changing for the future, and it's not at all a slap to the APA," he said. "We have cordial relations with people who developed the DSM and we have a shared interest in psychiatric diagnosis. It still remains the best instrument for diagnosing medical disorders today and to direct people to effective treatment."

But, he said, the way scientists are looking at mental illness is a "real shift" from the past.

Just as doctors can measure blood pressure, brain researchers hope in the future to have similar tools to measure the circuitry of the brain, which governs so much of behavior. The weakness of the DSM-5 is that it looks at a collection of symptoms, rather than the brain activity behind it.

A good example is the way in which anxiety disorders are classified in a group -- ones like post-traumatic stress disorder [PTSD], specific phobias, agoraphobia, according to Cuthbert. The DSM "assumes" they are all fear disorders. But brain research has found that "the more overall distress and misery" [patients] report, the more blunted their fear activity [in the brain].

Patients with PTSD who've had a single traumatic event show the biggest fear response of all groups, he said.

"However," he added, "if you look at patients with multiple traumas, they showed a smaller fear reaction -- almost like no fear at all."

"We need a reliable measure to see if one patient's fear is an elevated or blunted response before we look at groups of patients and assume everyone in the group has the same things wrong with them," said Cuthbert.

Some have accused the RDoC supporters of being interested only in drug therapies for brain disorders but, Cuthbert said, "That's not necessarily true. We are also interested in behavior therapy and a better understanding of how circuits produce behavior so we can develop treatments."

The APA's Kupfer said that the DSM-5 will work as a complementary diagnostic guide to the RDoC. But, he added, brain science has so far not produced the treatment results that many individual patients are waiting for.

"I went into psychiatry believing, like other areas of medicine, that we would have much better ways of treating those chronic disorders that attracted me in the first place," said Kupfer. "But I am beginning to be more impatient, and that is the key. I can't say [to individual patients], 'Help is on its way -- just tough it out for 10 years.' It's just not fair."

Despite that, he said, he has high hopes for improving care for mental health patients.

"We never want to think our children or grandchildren will only have the same possibility of treatment and interventions that we have today."

Q and A: APA on Changes in the DSM-5

ADHD: Will DSM-5's changes increase the prevalence of ADHD among teens and adults?

APA: Revisions to ADHD criteria were aimed at helping clinicians more precisely recognize the symptoms of individuals with ADHD to facilitate the right care for the right person. No one should ever be diagnosed without a careful, comprehensive assessment, and no medication should be prescribed without equal vigilance.

Autism Spectrum Disorders: Will DSM-5's changes to autism result in a loss of services for many people?

APA: Anyone accurately diagnosed with autistic disorder, Asperger's disorder, childhood disintegrative disorder, or pervasive developmental disorder not otherwise specified using DSM-IV should still meet the criteria for ASD or another diagnosis using DSM-5.

Bereavement Exclusion: Does DSM-5 turn normal grief into a mental illness?

APA: No. Removing the bereavement exclusion helps prevent major depression from being overlooked and facilitates the possibility of appropriate treatment, including therapy or other interventions. While grief and depression share some features like intense sadness and withdrawal from customary activities, grief and depression are also different in important aspects. DSM-5 includes language in the criteria and text for MDD to help distinguish between normal bereavement and a mental disorder.

Disruptive Mood Dysregulation Disorder: Does DSM-5's disruptive mood dysregulation disorder (DMDD) turn temper tantrums into a mental illness?

APA: The symptoms of DMDD go beyond describing temperamental children to describing those with clinically significant severe mood and behavioral dysregulation and -- unlike pediatric bipolar disorder -- irritability that is chronic rather than episodic. The threshold for DMDD is high and children must meet several diagnostic criteria. Current diagnostic guidelines do not provide an appropriate diagnosis for these children resulting in misdiagnosis. These criteria clarify the nature of episodic versus non-episodic irritability and promote accurate and consistent diagnosis for these children.

Binge Eating Disorder: Does binge eating disorder pathologize overeating?

APA: Binge eating disorder is much less common and far more severe than overeating. It is associated with significant physical and psychological problems. People with binge eating disorder tend to have a higher co-morbidity of mood and anxiety disorders and sometimes have a lower quality of life.

Gender Dysphoria: Why is gender dysphoria being included in DSM-5?

APA: Gender dysphoria replaces the diagnostic name "gender identity disorder" and makes other important clarifications in the criteria to respect the patient and ensuring access to care. The addition of a post-transition specifier for people who are living full-time as the desired gender (with or without legal sanction of the gender change) ensures treatment access for individuals who continue to undergo hormone therapy, related surgery, or psychotherapy or counseling to support their gender transition. Replacing "disorder" with "dysphoria" in the diagnostic label is not only more appropriate and consistent with familiar clinical sexology terminology; it also removes the connotation that the patient is "disordered" because of their gender nonconformity.

Hoarding Disorder: Has hoarding been added to DSM-5? Why?

APA: Research shows that hoarding is a distinct disorder. Using DSM-IV, individuals with pathological hoarding behaviors could receive a diagnosis of obsessive-compulsive disorder (OCD), obsessive-compulsive personality disorder, anxiety disorder not otherwise specified or no diagnosis at all, since many severe cases of hoarding are not accompanied by obsessive or compulsive behavior. Creating a unique diagnosis in DSM-5 will increase public awareness, improve identification of cases, and stimulate both research and the development of specific treatments for hoarding disorder.

Post-Traumatic Stress Disorder: What is changing in regards to post-traumatic stress disorder?

APA: PTSD will be included in a new chapter in DSM-5 on Trauma- and Stressor-Related Disorders. Compared to DSM-IV, the diagnostic criteria for DSM-5 draw a clearer line when detailing what constitutes a traumatic event. Sexual assault is specifically included, for example, as is a recurring exposure that could apply to police officers or first responders. DSM-5 pays more attention to the behavioral symptoms that accompany PTSD and proposes four distinct diagnostic clusters instead of three. They are described as re-experiencing, avoidance, negative cognitions and mood, and arousal.

Social Anxiety Disorder: Isn't social anxiety disorder just shyness?

APA: No. Social anxiety disorder is about more than just shyness and can be considerably disabling. A diagnosis requires that a person's fear or anxiety be out of proportion -- in frequency and/or duration -- to the actual situation. The symptoms must be persistent, lasting six months or longer. In DSM-IV, the time frame was required only for children; DSM-5 expands this criterion to include adults as well. The minimum symptom period reduces the possibility that an individual is experiencing only transient or temporary fear.

Somatic Symptom Disorder: Will DSM-5's somatic symptom disorder cause medical problems to be missed or be mislabeled as mental disorders?

APA: DSM-5 criteria encourage clinicians to more comprehensively consider the patient's behaviors, thoughts, and feelings, rather than focus primarily on whether or not the presenting physical symptoms can be medically explained. Most patients with medical disorders are not likely to have the dysfunctional thoughts, feelings, and behaviors that characterize SSD. However, a patient may have both medically explained symptoms from a non-psychiatric medical disorder as well as excessive thoughts or worries about their symptoms that result in clinically significant distress or impairment. Therefore, an SSD diagnosis does not mean that a non-psychiatric medical disorder is not present and cannot be diagnosed.

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