An updated manual of guidelines for the diagnosis of mental disorders goes on sale Wednesday after stoking long-standing controversy over its new characterization of some disorders, including combining autism disorder and Asperger's syndrome as different levels of the same problem.
Diagnostic and Statistical Manual of Mental Disorders 5, which the American Psychiatric Association made public Saturday at its annual meeting in San Francisco, contains guidelines that mental health professionals use to diagnose and treat mental disorders.
But DSM-5 has kicked up controversy ever since the APA announced plans to group autism, Asperger's, childhood disintegrative disease and pervasive developmental disorder as different levels of the same disorder.
That, among other changes from DSM-4, released in 1994, prompted the National Institute of Mental Health to announce three weeks ago that as the world's largest funding agency for research in mental health, it was withdrawing support for the manual. It said it won't fund research projects that rely exclusively on DSM criteria because it considers the manual to be lacking in scientific validity.
Other issues subject to debate include disruptive mood dysregulation disorder, a diagnosis for children who regularly overreact with temper tantrums. The manual also will consider bereavement of a loved one as a potential form of depression if it shows potential to lead to harmful behavior.
But the category of autism spectrum disorders is a lightning rod for criticism.
"There can be enormous differences between someone with Asperger's syndrome versus someone with autism," said Brent Robbins, who heads the psychology department at Point Park University and is a leading critic of DSM-5. "You lose information when you go in the direction of reducing the categories from four to one."
He said the rationale for the change is unclear.
"I don't know why they're doing that, moving in the direction that seems to get rid of distinctions," he said. "There might be some similarities in treatment, but the more severe autism disorder can require medication due to management of aggressive behaviors or self injury, which is less likely with Asperger's."
David Kupfer, chairman of the DSM-5 Task Force and former chairman of UPMC's Department of Psychiatry, said it's more accurate to identify the four as different levels of one mental illness, which allows clinicians to determine how disorders may relate to each other based on symptoms and better determine treatment and availability of educational and rehabilitative services.
"The basic problem is that those disorders could not be separated out from each other in an intelligent way for clinicians to make specific diagnoses," he said. "We felt based on all information that it made a tremendous amount of sense to bring them together and not have four separate diagnoses."
Including all four into one category raises concern among parents that their child with Asperger's will have the stigma of having autism, which often includes more severe behaviors and impairments. "These disorders are different, and this will cause more confusion than clarification," Mr. Robbins said. "I don't think there is good scientific reason to do that."
Other fiercely debated issues include the newly defined disruptive mood dysregulation disorder, or excessive temper outbursts occurring three or more times a week in children younger than 10. Mr. Robbins said he fears children may be misdiagnosed with DMDD because of temper tantrums and be prescribed psychotropic medications that can have serious health consequences.
Mr. Robbins said a diagnosis of DMDD is yet to be supported by science. For that reason, he said any parent whose child is diagnosed with DMDD should get a second and even third opinion before allowing the child to be placed on medication. "The language between normal temper tantrums and DMDD needs more investigation," he said. "It's a very fuzzy boundary."
Yet another concern are new guidelines allowing for the diagnosis of someone bereaving the loss of a loved one to be diagnosed with depression. DSM-4 generally did not allow for such a diagnosis until two months after the death occurred, because grief is natural. But Dr. Kupfer said DSM-5 will allow depression to be diagnosed at any point if the grieving person exhibits behavior that could lead to injury or suicide.
"What's different now is, if a person becomes suicidal one month after the loss of a loved one, we should be able to intervene in a clinical manner," he said.
Mr. Robbins has led petition drives against DSM-5 with an effort now underway to establish a new set of diagnostic guidelines based upon solving a person's problems based on specific symptoms rather than a focus on diagnosis. A new set of guidelines, however, could take a decade or two to complete.
But Dr. Kupfer said people should read the 947-page DSM-5 and use it in their medical practice before judging it.
"That's the kind of criticism I would like to see after people begin to use it and tell us what is not working so well," he said. "We have spent almost 14 years bringing together several thousand people and 500 of the best clinicians and researchers around the world to work with us to develop this manual.
"These criticism are made by people who have not read DSM-5 and don't have the best and most accurate information in their hands," Dr. Kupfer said.
David Templeton: email@example.com or 412-263-1578