The draft of the new ‘psychiatric bible’ is published

The draft version of the American Psychiatric Association’s DSM 5, the psychiatric ‘bible’ that defines the revised criteria for diagnosing mental illness, has finally been published.

It’s a masterpiece of compromise – intended to be largely backwardly compatible, so most psychiatrists could just get on diagnosing the few major mental illnesses that all clinicians recognise in the same way they always did, with some extra features if you’re an advanced user.

One of the most striking extra features is the addition of dimensions. These are essentially mini questionnaire-like ratings that allow the extent of a condition to be numerically rated, rather than just relying on a ‘you have it or you do not’ categorical diagnosis.

For example, the proposed dimension of emotional distress in depression is available online as a pdf and you will recognise the format if you’ve ever filled out a mood questionnaire. Take this item for example: “I felt worthless…” Never / Rarely / Sometimes / Often / Always.

One of the most striking changes is to the diagnosis of schizophrenia, which, although the core features remain the same, has changed radically in some ways. This is interesting because many people thought it would be largely untouched with just the addition of dimensions, but actually it’s been fundamentally restructured.

For many years, schizophrenia has been divided into various subtypes: paranoid schizophrenia, disorganised schizophrenia, catatonic schizophrenia, and the like, that reflect different symptom profiles.

The subtypes are currently a mess. It’s possible for two people to be diagnosed with schizophrenia with not a single psychological symptom in common and the groupings were made on a rather ad-hoc basis.

In the draft version the subtypes have been completely eliminated and instead, the replaced by dimensions, reflecting the fact most of the symptoms occur in different patients at different severities and that symptom profiles can change over time.

There is also a long overdue fix. Catatonic schizophrenia is a subtype that describes a pattern where patients have movement problems: catatonia – like being ‘frozen’ in one place or having an unusual symptom called waxy flexibility where no movement is initiated but if a limb is moved, it just stays there – a bit like a bendy doll.

It’s an unusual condition that was first described by the psychiatrist Karl Kahlbaum in 1874, but which isn’t actually specific to schizophrenia. In fact, it is more likely to turn up alongside severe depression and bipolar disorder, or in some types of brain damage, and is treated in a completely different way to schizophrenia, responding best to anti-anxiety drugs and ECT.

For reasons of misguided convenience, and against the best knowledge that was around for a century, it got classified as a subtype of schizophrenia. In a move that will have older psychiatrists rolling their eyes in a ‘I told you so’ sort of way, it is now a specifier that can just be plonked onto pretty much any other diagnosis if it occurs.

One of the changes likely to have the widest and most controversial effects is the creation of the ‘Psychosis Risk Syndrome‘ – a sort of something’s-a-bit-strange-but-you’re-not-completely-mad state, where people might have hallucinations, delusion-like ideas and disorganised thoughts, but not to the extent that they are completely disabled by them.

This is drawn from research on what has been called the ‘prodromal’ or ‘at risk’ mental state with the hope that it could identify and treat patients before they become properly psychotic.

One difficulty is that only about a third of people identified as being ‘at risk’ actually become psychotic at a later date. This wouldn’t be particularly worrying were it not for the fact that people in this ‘at risk’ state (perhaps better called 1-in-3 chance state) are often prescribed antipsychotic drugs.

As the first effective treatment for madness, antipsychotics are some of the most important drugs in medical history, but they are also some of the most toxic with long-lasting effects on the body and brain. The thought of giving them out to large numbers of people who might never become psychotic frightens many.

There is also the issue that this diagnosis might pathologise lots of eccentric but perfectly functional people. Research has shown that about %10 of Joe Public have higher levels of hallucinations and delusion-like ideas than the average psychotic inpatient but are rarely bothered by their experiences.

In other words, lots, and I mean lots, of people have unusual experiences – hearing voices, magical ideas, expansive moments – that never cause them any problems, but these people could now be diagnosed with a form of not-quite-mental-illness.

The other diagnoses that have received a radical rethink are the personality disorders which have been completely reconceptualised. Interestingly, the idea has been brought more in line with psychological definitions of personality and the consequent disorders are described as being disruptions to the self (identity integration, integrity of self-concept, and self-directedness) and interpersonal relations (empathy, intimacy and cooperativeness, and complexity and integration of representations of others).

A new child diagnosis of Temper Dysregulation Disorder with Dysphoria has been added. If this seems unremarkable it’s actually big slap in the face for a small but vocal group of US psychiatrists who have been pushing the idea of ‘child bipolar disorder’ – arguing that sad children who have tantrums are showing a juvenile form of ‘manic depression’.

This has become popular, almost entirely in the US, and has led to the alarming rise in children taking antipsychotics. The LA Times reports that this new diagnosis has been created in large part to stop kids being diagnosed with child bipolar. That’s the slap.

Many of the other changes are largely bug fixes. The much discussed change where Asperger’s syndrome and autism have been combined into autism spectrum disorder fixes the anomaly that the only difference between Asperger’s and high functioning autism was a technical point about what age the child started talking.

Post-traumatic stress disorder has been tightened up so it doesn’t rely solely on someone’s self-definition of trauma, preventing PTSD being diagnosed after seeing disasters on TV or after being troubled by upsetting but everyday events, such as insults at work.

The sexual disorders see quite a few additions including hypersexual disorder, that attempts to define being too interested in sex as a mental illness, and paraphilic coercive disorder, that is likely to cause legal controversy as it defines being turned on by forcing people into sex as a psychiatric problem, rather than a moral failing.

Binge-eating disorder has been added, addiction diagnoses for specific drugs have been created (included cannabis withdrawal), gambling addiction has been added, and the manual mentions ‘internet addiction’ in the non-committal, we need more information category.

Another interesting change is to conversion disorder, traditionally known as ‘hysteria’, where medical symptoms appear – such as paralysis – without the usual tissue or nerve damage. The Freudian theory is that the mind is ‘converting’ trauma into physical symptoms to protect consciousness from the mental pain, but the last remnants of Freud have been removed.

Previously, the clinician had to attribute motivations, unconscious or otherwise to the symptoms, but now they just have to appear without being explained by “a general medical condition, the direct effects of a substance, or a culturally sanctioned behavior or experience”.

The related cluster of dissociative and somatoform disorder have also been subtly de-Freuded, as American psychiatry presumably wishes to finally put the old Viennese ghost to rest.

As for the scientific basis of the disorders as distinct separate entities rather than somewhat cobbled together pragmatic descriptions, a quote in The New York Times article hits the nail on the head:

The good news, said Edward Shorter, a historian of psychiatry who has been critical of the manual, is that most patients will be spared the confusion of a changed diagnosis. But “the bad news,” he added, “is that the scientific status of the main diseases in previous editions of the D.S.M. — the keystones of the vault of psychiatry — is fragile.”

Link to draft version of the DSM-V.
Link to Washington Post coverage.
Link to New York Times coverage.
Link to LA Times coverage.
Link to Wall Street Journal blog coverage.
Link to NPR coverage via Integral Options Cafe.