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CHAPTER SEVEN The future

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CHAPTER SEVEN

The future

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hroughout this book I have shown how the DSM currently matters hugely. Even small changes can affect the lives of millions. In this last chapter, I look to the future. I shall explain why it is that I think the current dominance of the DSM is by no means guaranteed to continue.

In looking ahead, the key point to bear in mind is that we should not assume that the DSM will long continue to exist in anything like its current form.

At the outset, it is worth noting that is likely that the DSM-5 will be the last time that the DSM comes to be revised all in one go and published in book form. The system for numbering volumes has been shifted to facilitate the publication of more regular smaller-scale revisions as and when needed. Rather than

DSM-6 being published in 2030, we will have DSM 5.1, DSM

5.2, and maybe DSM 5.3.2.7 (Brauser, 2011; Verhoeff, 2010). This is all to the good. As mentioned previously, the current system meant that important copy editing errors in DSM-IV only came to be revised six years later. A process that allows for more frequent and easier updating can only be a good thing.

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CHAPTER SIX The field trials: DSM-5 and the new crisis of reliability

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CHAPTER SIX

The field trials: DSM-5 and the new crisis of reliability

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t time of writing, the DSM-5 has only just been published, and studies showing what differences the revisions have made to clinical practice, research, or service provision, are unavailable. The DSM-5 field trials are currently the best estimators of likely effects. This chapter focuses on one particular issue that has become controversial following the field trials: reliability.

The diagnosis that a patient receives should depend on the symptoms, rather than on who does the diagnosing. Suppose a patient sees a clinical social worker in the United States and is judged to have schizophrenia. If a reliable classification system is used then it should enable, say, a psychiatrist in Kenya, to decide on the same diagnosis.

When the DSM-III was published in 1980, it was presented as solving the problem of ensuring diagnostic reliability (APA,

1980, pp. 467–472). The story told was that while in the dark days of psychoanalytic dominance a patient judged neurotic by one therapist might well appear psychotic or normal to another, with the employment of the DSM-III patients could expect to be given the same diagnosis by all clinicians. Proof of

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CHAPTER FOUR Issues of content: the birth of a new diagnosis—hoarding disorder

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CHAPTER FOUR

Issues of content: the birth of a new diagnosis—hoarding disorder

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his chapter focuses on one of the new additions to the

DSM-5 that has garnered the least discussion. It will act as an illustration of how changes to the DSM come about, what impact they may have, and how even the least controversial of them can be problematic.

Hoarding disorder is included as a separate disorder for the first time in the DSM-5. In the DSM-IV, hoarding is mentioned only as a possible symptom of obsessive-personality disorder.

The campaign to have hoarding upgraded to a recognised distinct disorder started some time ago. In 1996, a key researcher in the area, Randy Frost, together with Tamara Hartl, published a paper on hoarding that included criteria for the disorder’s diagnosis. They suggested that clinical compulsive hoarding might be defined on the basis of

(1) the acquisition of, and failure to discard, a large number of possessions that appear to be useless or of limited value; (2) living spaces sufficiently cluttered so as to preclude activities for which those spaces were designed; and (3) significant distress or impairment in functioning caused by the hoarding. (Frost & Hartl, 1996, p. 341)

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Chapter One - DSM-5: An Overview of Changes

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These days, as soon as one edition of the DSM goes to press, work on the next begins. The revision process that culminated in the publication of DSM-5 thus started long ago; with pipe dreams that finally came to nothing. An early publication, A Research Agenda for DSM-V (the Latin numerals only changed later) set out the ambitions (Kupfer, First, & Regier, 2002). A Research Agenda for DSM-V is an extraordinary document. The book doesn't consist of plans for DSM-5 but rather of plans for plans; a series of “white papers” outline research priorities in various areas relevant to psychiatric classification. It is a testament to the phenomenal success of the DSM that such a book should be published, and not only published but published in paperback; research proposals related to psychiatric classification now find a mass readership. The very term “white paper”, used by the editors to describe the chapters, is more normally associated with plans produced by the offices of nation states. Though partly bluster, such self-importance is basically justified. Given that millions of people worldwide suffer from mental disorders, and that the DSM diagnosis someone receives can determine whether and how they are treated, changes to the DSM can potentially affect the lives of as many people as changes in the policies of most countries.

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CHAPTER FIVE Issues of content: the changing limits of autistic spectrum disorders

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CHAPTER FIVE

Issues of content: the changing limits of autistic spectrum disorders

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his chapter tells a story of changes in definitions, of prevalence rates, and of costs, all entwined. The headline news with regard to autism and related conditions is that

Asperger’s disorder has been removed as a standalone diagnosis from the DSM-5. Instead the new category autistic spectrum disorder (ASD) includes most of those previously diagnosed with autism as well as most of those previously diagnosed with

Asperger’s disorder. Also subsumed into ASD are the DSMIV diagnoses of Rett’s disorder—a rare genetic condition; and

PDD-NOS—pervasive developmental disorder not otherwise specified—a ragbag code for those with autism-like disorders who didn’t fulfil the criteria for any specific disorder.

Amongst researchers, whether Asperger’s should be considered to be a distinct condition, or merely the mildest form of autism, continues to be a source of contention (for a review see Matson & Wilkins, 2008). With the changes to the DSM-5, at least for the time being, those who advocate that there is no distinction between Asperger’s and high-functioning autism have won. The committees responsible for the change argue that the distinctions between Asperger’s, autism, and PDD-NOS imposed by the DSM-IV could not be reliably drawn. DSM-IV criteria for Asperger’s require that early language development

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