Why I’m Going to Use the New DMS-5 for Treating Patients

Health and medicine explained.
May 17 2013 11:27 AM

The DSM-5 Is Not Crazy

Psychiatry’s new diagnoses of picking, bingeing, and tantrums sound silly, but they’re useful for me and my patients.

A child throwing a tantrum lying down on the floor with her hands covering her face.
A child throwing a tantrum lying down on the floor with her hands covering her face.

Photo by iStockphoto/Thinkstock

Several new diagnoses appear in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, released later this month, and critics are attacking with claws extended. Controversy surrounds whether several of these new disorders should be included, and many experts question their validity.

Even Allen Frances, psychiatry professor emeritus at Duke University, who chaired the task force for the previous edition, the DSM-IV, called the day on which the DSM-5 was approved “a sad day for psychiatry.” Of greatest concern is the new manual’s potential to over-pathologize human behavior.

One of the most controversial new diagnoses, which Slate has covered before, is Disruptive Mood Dysregulation Disorder. It is intended to describe children between 6 and 18 years of age who show some signs of potential childhood-onset bipolar disorder. The category’s hallmark criteria are “temper outbursts that are grossly out of proportion in intensity or duration to the situation.” Yes, that’s right. It sounds like temper tantrums.

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Another controversy has erupted around Binge Eating Disorder. Bingeing, or eating a large quantity of food in a shorter period of time than is typical, is a disordered behavior according to the DSM-5. An individual who has eaten excessively at least 12 times in a period of three months meets criteria for Binge Eating Disorder. Frances calls Binge Eating Disorder one of the “top 10 changes to be ignored,” noting that bingeing is “no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM has instead turned it into a psychiatric illness.” (In fairness, bingeing is not a novel concept. It was previously listed as one of a number of potential symptoms used to diagnose a range of eating disorders, or it could be identified on its own as falling into the category Eating Disorder Not Otherwise Specified.)

It’s unclear what the new diagnostic criteria mean for most people. It could mean that children with temper tantrums (that would be most kids, right?) could potentially be evaluated and/or treated for a psychiatric illness. Tantrums may become more than tantrums, but rather potential symptoms of mental illness. Anyone who eats like it’s Thanksgiving a few too many times within a few months may be considered mentally ill.

However, there’s more to this than simply saying our culture is moving toward pathologizing normal behavior. The DSM-5’s heart is in the right place. In many cases the authors of the new manual have added categories to keep people from being wrongly labeled with a more severe disorder. Having the category Disruptive Mood Dysregulation Disorder may deter clinicians from prematurely diagnosing bipolar disorder, a serious mental illness with associated stigma that is often treated with medications that carry a host of potentially significant adverse effects.

The DSM-5 also adds skin picking (Excoriation Disorder) to its list of new diagnoses, which is characterized by repetitive skin picking that results in lesions, accompanied by recurrent unsuccessful attempts to cease the behavior. Critics have asserted that everyone picks their skin as a normal part of grooming behavior and turning such a behavior into a psychiatric illness will result in the inappropriate diagnosis of many normal individuals with normal behaviors. But skin picking is more than popping a few pimples. Yes, everyone picks at his or her skin at some point; however, skin picking as a disorder extends to picking, scraping, or gouging that results in scarring or disfigurement.

I see patients who struggle with skin picking, and they are seeking therapy because it has started to interfere with their ability to have a normal life.  It’s important to remember that the DSM-5 is written for clinicians who are seeing patients with a set of troublesome symptoms. It’s not a catalog for the general public to browse through in order to identify problems in themselves or others. Binge Eating Disorder has been included for the benefit of a therapist seeing a patient who worries about his binge eating and its negative impact on his life, not to pathologize everyone at an all-you-can-eat restaurant.

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