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Debate over psychiatry bible DSM-5 grows days before release

With the release of the fifth edition of the so-called psychiatrist's bible -- the "Diagnostic and Statistical Manual of Mental Disorders (DSM)," days away, the controversy surrounding the new publication is heating up.

The National Institute of Mental Health (NIMH) and the American Psychiatric Association (APA), which publishes the DSM, issued a clarifying statement Tuesday saying that they were working together to ensure that people with mental disorders would have better diagnostic resources available to them. However, while they emphasized that the new version, dubbed the "DSM-5," will have the most up-to-date information for clinical diagnoses of mental disorders, the NIMH did not waver from its initial ruling that it would no longer use diagnoses listed in the DSM for its' funded studies.

NIMH director Thomas Insel wrote in a statement earlier in May that the NIMH felt the proposed definitions for psychiatric disorders were too broad and ignore smaller disorders that were lumped in with a larger diagnosis.

"The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever," Insel said.

Instead, researchers will be asked to rely on the Research Domain Criteria (RDoC) project, a new classification system that will take into account genetics, cognitive science, imaging and other sources of information. The NIH and APA emphasized that the DSM-5 and RDoC are not meant to compete against each other.

"DSM-5 and RDoC represent complementary, not competing, frameworks ... As research findings begin to emerge from the RDoC effort, these findings may be incorporated into future DSM revisions and clinical practice guidelines," the organizations said in the May 14 statement. "But this is a long-term undertaking. It will take years to fulfill the promise that this research effort represents for transforming the diagnosis and treatment of mental disorders."

The DSM-5, which has been vetted by more than 1,500 experts and was open to public comment over the past year, will mark the latest major revision of the psychology reference guide in two decades. It is set to be released at the APA's annual meeting, which will begin in San Francisco on Saturday. Many arguments have erupted about the definitions in the edition, including the fact that Asperger's syndromeand child disintegrative disorder have been dropped and included under the blanket autism diagnosis.

A new book written by the chairman of the task force for the DSM-IV  -- the previous version of the manual from 1992 -- was published on Tuesday, criticizing the changes.

"This is not just an academic debate," author and psychiatrist Allen Frances told USA Today. "It's not just inside psychiatry. It has a huge impact on how lives are lived, how mental health dollars are spent and on the public health of the country."

One petition created by doctors protesting the new manual's release has received over 14,747 signatures as of Tuesday. The medical groups behind the petition claim that many of the diagnostic categories have "questionable reliability" and did not have extensive scientific review, which may hurt patients since it may now be easier to be diagnosed with these disorders. Gordon Parker, scientia professor of psychiatry at Sydney-based University of New South Wales, called the new edition "an example of psychiatric imperialism," at a press conference with other Australian academics, according to Bloomberg Businessweek.

"(The DSM-5 has) a flawed logic and a flawed model which leads to compromised research and also compromises management," he commented.

Another expert, Dr. Gin Malhi, a psychiatry professor at the University of Sydney in Australia, published a comment in The Lancet on May 10 on the new DSM-5 definition for bipolar disorder, expressing his concerns. Bipolar disorder is marked by states of extreme mood highs called mania and extreme lows called depression that a patient cycles through. Mahli felt that the DSM-5's inclusion of a "mixed state specifier" in the definition -- meaning depressive and manic states can exist at the same time -- may create confuse diagnosing clinicians and lead to improper treatment.

In previous editions, specifically the DSM-IV, mixed states had a more specific definition that included experiencing all the manic and depressive episode symptoms for at least a week. According to the DSM-5, a patient just has to have either mania or depression and three symptoms from the opposite state. Mahli added that he felt the new definition will make it so more people are diagnosed with bipolar disorder, many of whom would be misdiagnosed.

"The risk is that [the diagnostic criterion of mixed states] will be used loosely and its application will expand far beyond bipolar disorder type I and across the whole bipolar spectrum, without any prognostic significance of therapeutic benefit," he wrote.

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