US DSM-5 for diagnosing mental disorders published - Asperger's is Out!

In the manual, grief is newly medicalised as major depressive disorder (MDD). 

Credit: Adam G. Gregor /Alamy

The field of mental health will face its greatest upset in years on Saturday with the publication of the long-awaited and deeply-controversial US manual for diagnosing mental disorders.

Early drafts of the book, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, have divided medical opinion so firmly that authors of previous editions are among the most prominent critics.

Known informally as the psychiatrists' bible, the $199 tome from the American Psychiatric Association is the guidebook that US doctors will use to diagnose mental disorders. The latest edition is the first major update in 20 years.

Though not used in the UK, where doctors turn to the World Health Organisation's International Statistical Classification of Diseases (ICD), the US manual has global influence. It defines groups of patients, and introduces new names for disorders.

Those names can spread, and become the norm elsewhere, but more importantly, the categories redefine the populations that are targeted by drugs companies.

Criticisms have come from almost every corner. There are claims of expansionism, with common experiences and behaviours becoming newly medicalised.

Allen Frances

Temper tantrums become Disruptive Mood Dysregulation Disorder (DMDD); grief becomes major Depressive Disorder (MDD), according to Allen Frances, an American psychiatrist who chaired the task force behind the fourth edition of the manual.

Other behaviours get their own labels: overeating becomes binge eating disorder; keeping too much junk, a hoarding disorder; a bit forgetful could be mild neurocognitive disorder.

David Clark

David Clark, professor of experimental psychology at Oxford University, said "Mental health disorders are often hard to divide into clear categories, because too little is known about them, and there can be major overlaps. But the definitions are often valuable. For example, greater distinctions between various types of anxiety have led to more specific and effective treatments."

Nick Craddock, professor of psychiatry at Cardiff University, and director of the National Centre for Mental Health in Wales, said "Some of the stranger aspects of the US manual will have no impact in Britain. DSM-5 was flawed because definitions of disorders were sometimes changed on the basis of too little fresh scientific evidence."

"I don't believe the science has advanced sufficiently in 20 years since DSM-4 to warrant making a new system," he said. "That essentially is just a group of people agreeing on tweaking things and making them appear a little bit different. That to me is not a very helpful stage in the develop of psychiatric diagnosis. This is the wrong time in history to change the diagnostic system."

Changing the definitions of disorders alters who has them. That affects who gets drugs and other support, and who interventions are trialled on. If the criteria for attention Deficit Hyperactivity Disorder (ADHD) are broadened, then more people are likely to be diagnosed with the condition.

The arrival of DSM-5 will mean the end of Asperger's syndrome in the professional eyes of the US psychiatric arena.

Along with some other autism-related conditions, Asperger's will now be consumed by the new category of "autism spectrum disorder".

Carol Povey

Some people diagnosed with Asperger's are unhappy about the coming change. Carol Povey, director of the National Autistic Society's Centre for Autism, said: "The term Asperger Syndrome is a core part of their identity for many people and they understandably feel anxious about moves to remove the term. The changes won't prevent people from continuing to use it to define themselves and nor should it," she said.

Debbie Tucker, chair of the Asperger's Syndrome Foundation, said the label can be useful in treating people, but that some did not want to be labelled. "Labels only become unhelpful and sometimes dangerous if used to discriminate. People with Aspergers are vulnerable to this," she said.

Thomas Inse

Last month, Thomas Insel, director of the National Institute of Mental Health, declared that the organisation would not use DSM-5 definitions to set its research priorities. Writing about DSM-5 on his blog, he said: "The weakness is its lack of validity. Unlike our definitions of ischaemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure."

Instead, he said the NIHM would lay the foundations for a new classification system, based on brain imaging, genetics, cognitive science and other research.

"We need to begin collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response," he said.

Stages of Grief - Is It Time For a New Model?

The face of Grief and mourning in our society is changing.

One wonders why the myth, that mourning or grieving happens in stages or phases, is still so prevalent in our enlightened society.

After all, there are other, more descriptive models that better describe the process. So what’s wrong with stage-based models of mourning?Well, several things.


Stage Theories
If there is a multitude of stage theories, which one is correct? There are theories involving three, four, five, six, seven, ten, and twelve different stages.

DABDA
The most famous model is a misapplication of Elizabeth Kubler-Ross’s five stages of coping with dying. The stages, popularly known by the acronym DABDA, include:

1. Denial — "I feel fine."; "This can't be happening, not to me."
   Denial is usually only a temporary defense for the individual. This feeling is generally replaced with heightened awareness of possessions and individuals that will be left behind after death. Denial can be conscious or unconscious refusal to accept facts, information, or the reality of the situation. Denial is a defense mechanism and some people can become locked in this stage.
2. Anger — "Why me? It's not fair!"; "How can this happen to me?"; '"Who is to blame?"
   Once in the second stage, the individual recognizes that denial cannot continue. Because of anger, the person is very difficult to care for due to misplaced feelings of rage and envy. Anger can manifest itself in different ways. People can be angry with themselves, or with others, and especially those who are close to them. It is important to remain detached and nonjudgmental when dealing with a person experiencing anger from grief.
3. Bargaining — "I'll do anything for a few more years."; "I will give my life savings if..."
   The third stage involves the hope that the individual can somehow postpone or delay death. Usually, the negotiation for an extended life is made with a higher power in exchange for a reformed lifestyle. Psychologically, the individual is saying, "I understand I will die, but if I could just do something to buy more time..." People facing less serious trauma can bargain or seek to negotiate a compromise. For example "Can we still be friends?.." when facing a break-up. Bargaining rarely provides a sustainable solution, especially if it's a matter of life or death.
4. Depression — "I'm so sad, why bother with anything?"; "I'm going to die soon so what's the point?"; "I miss my loved one, why go on?"
   During the fourth stage, the dying person begins to understand the certainty of death. Because of this, the individual may become silent, refuse visitors and spend much of the time crying and grieving. This process allows the dying person to disconnect from things of love and affection. It is not recommended to attempt to cheer up an individual who is in this stage. It is an important time for grieving that must be processed. Depression could be referred to as the dress rehearsal for the 'aftermath'. It is a kind of acceptance with emotional attachment. It's natural to feel sadness, regret, fear, and uncertainty when going through this stage. Feeling those emotions shows that the person has begun to accept the situation.
5. Acceptance — "It's going to be okay."; "I can't fight it, I may as well prepare for it."
   In this last stage, individuals begin to come to terms with their mortality, or that of a loved one, or other tragic event. This stage varies according to the person's situation. People dying can enter this stage a long time before the people they leave behind, who must pass through their own individual stages of dealing with the grief.

This model for mourning is the most egregious one since it is a totally erroneous application of her work.

Complex Process
Regardless of which one you chose, each stage theory attempts to portray a complex process involving the emotional, behavioral, cognitive, spiritual, and social facets of a person with a few simplistic terms.

While simplicity can help describe something, it can also be very misleading. There is no empirical proof that any stage-based model describes everyone’s bereavement experience.

The models have been based on observations of select populations and not, until recently, subjected to empirical study.

A Car Wash Approach

Stages imply that mourning is passive. A good analogy is a car wash. First is the “vacuuming the floor” stage, followed by the “clean the bugs off the windshield” stage, followed by the “wash, and rinse” stage, followed by the last stage - the “drying off” stage.

The car doesn’t do anything but be there, and everything happens to it so it comes out of the process bright and shiny clean. Mourning is not a passive process like a car wash; it is a highly active one.

Simple Expectations
Stage models create expectations of what mourning is supposed to be like. To me, this is a major shortcoming because of the potentially detrimental effect on the bereaved.

A widely published list of stages sets people up to expect certain reactions after the death of a loved one.

When those expectations don’t happen or don’t happen in the “correct” order, the bereaved individuals can think there is something wrong with them.

I have had several clients come to me stating they haven’t experienced one stage or another, and they're scared they're not grieving the way they should.

Once I explained to them that stages are an artificial construct, they were definitely relieved. There are typically enough complex and emotional possibilities for a bereaved person to work through, without adding whether he/she has adequately encountered all the 'defined' stages of grieving or whether the stages have occurred in the 'proper' sequence.


Conclusion
It is NOT a checklist that defines an established path. It is time we stopped trying to distill the inter-personal and intra-personal complexities of mourning into a simplistic template and a set of dogmatic steps.

Mourning is a highly individualistic process based on many complex factors in the bereaved person’s life.

It is a process for finding meaning in a distressing time of loss, transforming and /or creating a new relationship with the deceased, reintegrating the deceased into the bereaved person’s being, and learning how to live in the world under a new set of conditions and assumptions.

If you or anyone you know is experiencing difficulties dealing with their loss and bereavement then they should seek advice and support from a professional who can provide guidance and insight.