This month a hotly anticipated book will hit the shelves, and its publishers already know it will sell big. Likely to clock in at 1,000 pages, it's not one of the thrillers, sizzlers, or self-helpers that typically populate bestseller lists. The fifth edition of the DSM, or Diagnostic and Statistical Manual of Mental Disorders, will find a waiting nook in the library of any individual or organization paid to provide mental health and addiction care, including doctors and therapists, treatment programs, drug companies, and the insurance industry. Its ubiquitous influence has earned it the name "the Bible of psychiatry."
And that’s why you need to know about what’s inside it—and behind it. The big book plays a big role in the life of anyone seeking help for addiction, from the diagnosis you may get from your doctor to the bill your insurance company may send you. (It looms especially large for the 40 percent of addicts who have a dual diagnosis.)
The volume—published by the American Psychiatric Association (APA)—consists entirely of a labyrinthine system that classifies and categorizes diagnoses and symptoms of mental illness and addiction. And all for only $199.
The APA began work on this 2013 version of the DSM in the late '90s. The organization's stated goal was to improve all mental health care by rooting it deep in new science, recognizing the big strides in neuroscience made over the last two decades. Those advances have, for one thing, almost entirely redefined addiction as a brain disease.
But the manual has already sparked a raging controversy—one psychiatrist likened the kerfuffle to a “bar-room brawl" and "Armageddon"—and garnered much media attention (plus over 1,600,000 Google listings for “DSM-5”). Now, with the book still at the printer, one international psychology group has called for a boycott. What many overlook, however, is that the current battle represents a long-simmering conflict in psychiatry that goes public only at DSM revision time, but can be traced back to the late ‘70s.
Like the DSM’s two previous major revisions, published in 1975 and 1994, this one expands the number of psychiatric diagnoses and will almost certainly result in many more people receiving such a diagnosis. Advocates for DSM-5 say that the science justifies these changes; many critics see ulterior motives. The consequences of more people with more diagnoses are also at issue. Both sides agree that more diagnoses could mean earlier interventions. But will this lead to more effective—and more cost-effective—treatment strategies, saving precious resources as health care costs spiral out of control? Or to a cash cow for drug companies and doctors who prescribe psychoactive drugs, diverting already-scarce funds from the addicts who most need them?
HOW IS 'ADDICTION' CHANGING?
The DSM-5 is the first to include the word “addiction.” But this change is largely cosmetic, appearing only in the title of the section “Addiction and Related Disorders.” Previous versions shied away from this charged word, Charles O'Brien, MD, Ph.D., the head of the University of Pennsylvania’s Center for Studies in Addiction and the chair of the DSM-5's Substance-Related Disorders Work Group, tells The Fix.
The red meat of the new changes lies in the definitions of the conditions. The previous DSM identified two separate substance disorders: “substance abuse” and “substance dependence.” But the line dividing one from the other remained blurry. The DSM-5 collapses the two into one continuum, defining “substance use disorders” on a range from mild to moderate to severe; the severity of the diagnosis depends on how many of the six criteria apply. So rather than dividing the universe into “alcoholics” and “non-alcoholics,” for example, the new “alcohol disorder” spectrum could include everyone at levels from "mild" (your "normal" college binge drinker) to "severe" (someone whose drinking is out of control and who meets all six criteria). You can even be “almost” alcoholic, with four criteria.
The DSM's research showed that changes to criteria number were necessary to maintain accuracy after collapsing the two previous disorders. Now two criteria can earn you an “alcohol use disorder” diagnosis (previously “alcohol dependence” required three symptoms, while the milder “substance use” diagnosis required one). The latest manual also nixes the “legal problems” criteria (a lifestyle problem) and adds “craving” (a brain dysfunction). Studies have shown the importance of treating craving symptoms, whereas legal problems varied too greatly by location, O'Brien says.
The new DSM also puts one—and only one—“behavioral” disorder on a par with addiction to substances: "disordered gambling," which was previously dubbed "pathological gambling" and listed under "Impulse-Control Disorder." At one stage of drafting the new version, "Internet addiction disorder" was set to be included, but it has now been relegated to an obscure appendix of conditions “deserving of further study." The difference? Disordered gambling, a time-honored problem, had many more studies backing it up, O’Brien tells us. Other "disordered" behaviors—sex, eating, shopping, video gaming, etc.—aren't included at all, but will likely have their day in due course.
“There is substantive research that supports the position that pathological gambling and substance-use disorders are very similar in the way they affect the neurological reward system.”
HOW WILL DIAGNOSES BE MADE DIFFERENTLY?
Traditionally, psychiatric diagnoses have depended, to a large degree, on subjective measures: a patient’s experience and a therapist’s evaluation. But science is all about “objective” facts. The introduction of the “substance use disorder” as a severity scale is meant to help addiction treatment fall in line with physical medicine, with its numerically precise diagnostics like blood pressure and cholesterol levels.
“What we're trying to do is make the DSM-5 diagnoses more like a neuroscience diagnosis,” O'Brien says. “It allows for much more precise treatment.”
The DSM-5 also does away with the term “dependence,” which was widely misused and misunderstood, O'Brien says. The term led patients and doctors alike to confuse physical dependence with addiction. Though it plays a role in addiction, dependence refers only to the body's symptoms of tolerance and withdrawal in response to chemicals. It doesn't include the psychological compulsions that also contribute to people's inability to stop using.
The APA's ambitions toward better science also explain the inclusion of the first behavioral disorder as an official diagnosis under "Addiction." A burgeoning body of evidence shows that engaging in, say, compulsive cybersex has the same effect on the brain as overdoing cocaine. “There is substantive research that supports the position that pathological gambling and substance-use disorders are very similar in the way they affect the neurological reward system,” O’Brien told Recovery Today. PET scans and MRIs have demonstrated these physical changes in the brains of people with behavioral disorders and substance disorders alike.
WHO OBJECTS TO THE CHANGES AND WHY?
Better science behind psychological diagnoses? Earlier detection and treatment? What’s not to love about the new DSM? Quite a bit, according to critics.
The first, loudest, and longest-dissenting voice belongs to the man who ran the revision of the guide's previous incarnation, the DSM-IV: Allen Frances, MD, a professor emeritus in the department of psychiatry at Duke University Medical School, has penned one vitriolic editorial after another since 2009, calling the fifth edition “clearly unsafe and scientifically unsound” and accusing his own profession of being “in the business of inadvertently manufacturing mental disorders.”
What troubles Frances most is “diagnostic inflation.” His particular bugaboos include: “binge eating disorder,” defined by excessive eating 12 times in three months; the spectrum approach to substance disorders that lumps first-time abusers with hard-core addicts, despite vastly different treatment needs; and the recognition of behavioral addictions, “creating a slippery slope that can spread to make a mental disorder of everything we like to do a lot.”
Frances is not alone. An open letter from more than 50 mental-health associations says that, despite the APA's goal of a more scientific manual, science is precisely where the DSM-5 fails. Evidence does not support the new disorders or the dimensional measures, the letter says.
It also called for an independent scientific review of the proposed changes—a call the APA flatly refused, saying, “There is in fact no outside organization that has the capacity to replicate the range of expertise that DSM-5 has assembled.” In turn, many of the groups behind the original open letter have now called for a boycott of the DSM-5.
WHAT WILL BE THE CONSEQUENCES OF MORE DIAGNOSES?
Most observers agree that the DSM-5 will result in many more people getting diagnosed. This is likely to result in earlier treatment, and it is in this shift of resource allocation from, for example, the late-stage alcoholic to the “almost” alcoholic that all hell breaks loose.
Health care policy today places a premium on prevention. Second best are early detection and treatment, which result in better outcomes and lower costs than treating later-stage, acute disease—no minor concern in an age of out-of-control health care spending. The DSM-5 revision was guided by the same principles that pushed prevention in the nation's health care overhaul (popularly known as "Obamacare"), O’Brien tells The Fix. The substance use scale will steer more people who have taken the first steps toward developing a substance use problem into treatment, he says: “You save $7 for every $1 you spend on early care.”
Critics contend, however, that the bulk of early interventions will be wasted on many people who, having been diagnosed unnecessarily, don't need treatment. That, they allege, will leave many others with severe substance use problems—and inadequate resources for treatment—out in the cold. “Our scarce mental-health resources are already distributed in an irrational manner," Allen Frances wrote in Bloomberg News in December. "We badly shortchange those with clear psychiatric disorders while overtreating essentially normal people.”
Such diagnostic expansion will occur in many areas, critics say—but the boycott group specifically calls out lowered diagnostic thresholds for alcohol use disorder as one example. And at least one study supports that worry; research in Australia found that the DSM-5 recommendations would increase diagnoses of alcoholism by a whopping 61.7 percent. Such a large increase, due mainly to the criteria scale approach, could cause demand for services to overwhelm health care institutions, said Lisa Mewton, Ph.D., of University of New South Wales in Australia, the lead author of the study. (Two U.S. studies predicted much more reasonable increases, however.)
“Over-medicalization” is the core of the problem, Peter Kinderman, Ph.D., co-chair of the boycott group, and professor of clinical psychology at the University of Liverpool, tells The Fix. The DSM-5 turns isolated and unrelated psychological or social problems into symptoms and force-fits them into a medical condition, he says: “Problems should be treated as problems, not illnesses.”
Kinderman paints gambling, for example, as a psychological problem that should receive psychological intervention. Once labeled an illness, he argues, it's likely to be treated with medicines, expanding the market for drug makers.
Charles O'Brien, who has developed several new medications for addiction during his career at the University of Pennsylvania, agrees that the new DSM will lead to more use of psychoactive drugs for addiction. But that's because such treatments are more effective, he says. He relates the results of a CNN investigation, in which five addiction centers refused to use drug treatments, despite seeing evidence of their efficacy: All patients at those centers relapsed.
An open letter from more than 50 mental-health associations says that, despite the APA's goal of a more scientific manual, science is precisely where the DSM-5 fails.
HOW ARE BIG PHARMA DOLLARS MIXED UP IN THIS?
Diagnosis inflation is a bonanza for Big Pharma, which already makes hundreds of millions of dollars from the 20 percent of Americans who are prescribed psychoactive drugs. Many addicts with dual diagnoses already take these medications. With many substance users now likely to seek treatment earlier, clinicians will be incentivized to diagnose depression, anxiety, or another common mental problem alongside the addiction, and then send patients to psychiatrists who can prescribe drugs. In addition, the proliferation of new medical conditions in the DSM-5 gives drug makers the opportunity to market the same drugs for new indications.
“Drug companies will laugh all the way to the bank,” Frances wrote in a letter to The New York Times.
The ties among psychiatrists and drug companies are longstanding and deep. When it comes to taking money from Big Pharma, psychiatry consistently leads the pack of all medical specialties. Links to pharma among DSM-5 members have increased—rising by 20 percent since the book's previous edition, according to a study by Lisa Cosgrove, Ph.D., associate professor of clinical psychology at the University of Massachusetts-Boston, and Sheldon Krimsky, Ph.D., a professor of urban and environmental policy and planning at Tufts University.
That increase occurred despite a move by the APA to require that all DSM committee members disclose their industry ties. The findings show that “simply disclosing the conflict is not enough,” Krimsky tells The Fix.
In its response, the APA noted that 72 percent of DSM-5's members reported no ties to pharma last year. (However, that may mean the members cut ties only in 2012, the study notes.)
The medicalization of mental illness and addiction is not new. It began in the late ‘70s, and the DSM played a critical role. According to Marcia Angell, MD, the former editor of the New England Journal of Medicine, financial self-interest drove psychiatry’s redefinition of psychological problems as medical conditions. At the time, more and more psychologists and social workers were functioning as therapists, and psychiatrists moved to take back the field by playing their trump card: As medical doctors, they had the legal authority to write prescriptions. And diseases demand medicine.
The revision of the DSM led this realignment. In an aggressive media campaign, the APA announced that the new DSM-III would “remedicalize psychiatry” and offer “a defense of the medical model as applied to psychiatric problems,” Angell said. The official reason for the sweeping overhaul? Keeping up with the science. Sound familiar?
“By fully embracing the biological model of mental illness and the use of psychoactive drugs to treat it, psychiatry was able to relegate other mental health care providers to ancillary positions,” Angell wrote in the New York Review of Books in 2011. “Most important, by emphasizing drug treatment, psychiatry became the darling of the pharmaceutical industry, which soon made its gratitude tangible.”
HOW MUCH DOES THE DSM-5 MATTER, ANYWAY?
For some, the controversies surrounding the new manual have a simple solution: “I would tell people not to use it,” says Kinderman.
Other critics take a more balanced perspective, advising patients and practitioners simply to recognize that the DSM is not the sole authority for addiction diagnosis or treatment. Cosgrove advises patients and providers to investigate alternative guidelines, such as those developed by the British National Institute for Clinical Excellence (NICE), which incorporate perspectives beyond psychiatry.
Calls to end monopolies, particularly on topics as important and sensitive as psychiatric diagnoses, may sound eminently reasonable. But the practical realities of treatment also make such boycott efforts mostly symbolic, says psychologist Richard Juman, Ph.D., who formerly headed the New York State Psychological Association (and now coordinates The Fix's Professional Voices section).
So, for the foreseeable future, the DSM-5 is likely to remain psychiatry's Bible, if only because of the tyranny of insurance paperwork: Therapists, for example, need to provide a patient's DSM diagnosis on the bill in order to get paid. But while critics say the DSM-5 fails to recognize the complexity of individual patients, the pile-on of condemnation may underestimate the complexity of treatment providers: That is, clinicians already know that the DSM is an imperfect manual, and even as they use it institutionally to meet insurance requirements and as a symptom reference, they know to take each individual case as it comes. “There is nothing so radical in DSM-5 that clinicians will be unable to come up with an accurate diagnosis,” says Juman.
Clinicians will continue to take the DSM with a grain of salt, agrees Alexis Edwards, Ph.D., an assistant professor at the Virginia Institute of Psychiatric and Behavioral Genetics, whose own research identified some shortcomings in the new book's alcoholism diagnoses. "I have a lot of faith in clinicians that if they identify someone as having a problem, they'll find a way to help them," she says. "Guidelines are important, but they don't always have the right answer."
That practical skepticism, combined with the unprecedented criticism leveled at the DSM's fifth incarnation—and at psychiatry's increasing propensity to medicate patients—may signal a slow erosion of the publication's status. Ironically, critics calling for the DSM's abolition may grant it as much perceived authority as the proponents who want to make the manual scientifically precise. But in the hospitals and clinics where addiction and other forms of psychiatric suffering actually get treated, the guide is just a book—not a Bible. And its sway may be diminishing, even as the tome itself adds more and more pages and diagnoses.