Psychiatrists Redefine Disorders Including Autism
New guidance for the diagnosis of some mental disorders, including autism, was endorsed by U.S. doctors over the weekend, clearing the way for changes that will influence the way patients are treated and payments reimbursed.
The vote by the American Psychiatric Association follows a seven-year debate that split the mental health community over whether the changes will spur over-diagnosis of some disorders, and limit treatment for others. The guide collapses several conditions into a broadened definition for autism. It also adds new maladies, including one called disruptive mood dysregulation disorder for children who have multiple temper tantrums weekly.
The outcome of the ballot was alternately called “a disaster” by Allen Frances, who led work on the previous version, and a “conservative document” by David Kupfer, who led the panel that presented the latest edition. The guide is scheduled to be released in May at the psychiatric group’s annual meeting.
“I think we’ve improved our diagnostics, but this is not written in stone,” Kupfer said in a telephone interview after the vote. The committee that produced the new edition will monitor how the changes play out, he said.
The Diagnostic and Statistical Manual of Mental Disorders is the standard used by mental health professionals for diagnosing illness and for research. The newest edition, referred to as DSM-5, is meant to incorporate research in the 18 years since the previous major revision was completed in 1994.
A panel of experts from 90 universities worldwide revised the manual, at a cost expected to be about $25 million. One in 5 Americans experienced some form of mental illness this year, the U.S. Substance Abuse and Mental Health Services Administration reported in January. Mental health-care costs rose 63 percent to $57.5 billion in 2006 from a decade earlier, according to the National Institutes of Mental Health.
“It’s very controversial,” said Michael Berk, professor of psychiatry at Melbourne’s Deakin University. Most diagnoses in medicine are validated by physical manifestations of disease, “whereas in psychiatry, you have syndromes -- mood, anxiety, psychosis -- and you have symptoms built around those, and that is less valid than having a pathophysiology,” Berk said.
DSM is the most widely used classification system globally, he said. While it’s used primarily as a diagnostic manual, it helps sets the basis for clinical research. In the U.S., if a psychiatric disorder isn’t described in the manual, it doesn’t get reimbursed, Berk said.
“It’s of huge importance to the field,” he said.
Public criticism on the manual has grown over the last two years. A division of the American Psychological Association in Washington posted an open letter to the DSM panel a year ago that was signed by more than 14,000 people, including psychologists, counselors, and community activists.
In many cases, family doctors that don’t have extensive training in mental disorders will be using the new definitions, Frances said in a telephone interview after the vote was taken. “The thing I learned with DSM-IV is that if anything can be misused, it will be,” he said.
Among the revisions is a decision to collapse several conditions, including Asperger’s syndrome and child disintegrative disorder, into a single autism diagnosis.
Critics have said that the elimination of Asperger’s as a unique diagnosis may limit access to care for some high- functioning people who previously might have been diagnosed with the syndrome. A study presented at a medical meeting in Iceland in January suggested that as many as half of the high- functioning patients who had been diagnosed under the previous rules may be missed by the new ones.
“Although there is a strong scientific rationale for these changes, we are concerned about the impact when they are used in real-world settings,” said Geraldine Dawson, the chief science officer of advocacy group Autism Speaks, in an e-mailed statement. “We still have very little information about the impact of the DSM-5 on diagnosis of autism spectrum disorder in young children and adults.”
The autism changes will probably inspire further debate and study, said Emanuel Maidenberg, the director of the cognitive behavior therapy clinic at University of California Los Angeles.
“This won’t stop discussion of whether it’s justified or not,” Maidenberg said in a telephone interview.
While the inclusion of disruptive mood dysregulation disorder was controversial, Maidenberg said it could be used to prevent children from worse harm. Previously, many of these children had been classed as having bipolar disorder, which can result in aggressive drug treatment.
“Overdiagnosis is a reasonable concern,” he said. “But it’s a good diagnosis to have, in order not to go to bipolar.”
The manual also changes the definition of depression to include people who have experienced the death of a loved one within the last two months, and adds discussion notes on the notes on the difference between grief and depression.
The change is meant to reflect that deaths can sometimes trigger depression in those who are susceptible, the group said.
Excluded from the new book are items such as hypersexual disorder, in which patients can’t control their sexual urges; parental alienation syndrome, which describe stress from custody battles; and sensory processing disorder, where people experience the world as unusually loud or bright.
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