CAVANAUGH: Our top story on Midday Edition, the new diagnostic and statistical manual, or DSM5 compiled by the American psychiatric association was released to the public last weekend. It's gotten a lot of people riled up. The new edition that classifies mental disorders changes the designation of some autistic disorders, and some critics say it changes normal activities like overeating and grief into new illnesses of the mind. My guests, doctor Timothy Murphy is with the San Diego psychiatric society, and he's president elect of the California psychiatric association. He helped work on the DSM5. Welcome to the program. MURPHY: Thank you for inviting me. CAVANAUGH: Nicole Hope-Moore joins us as well, president elect of the autism society of San Diego. Thank you for coming in. HOPE-MOORE: Thank you for having me. CAVANAUGH: Now, first a general question, how often are these diagnostic manuals changed? MURPHY: Well, DSM4, which is the version we're using currently came out in 1994. Before that, the DSM3 had been published in 1980. So that was a difference of 14 years. The new DSM5 will have made a difference of 19 years since the previous edition. Of CAVANAUGH: How are these decisions made? Can you give us a sort of DSM101? What is the process that the board goes by to make these changes that we're seeing now in the DSM? MURPHY: Well, first, I should say that D SM3 and 4 were great achievements, and they established explicit operationalized criteria to better -- help us make better diagnoses. But over time, problems emerge. We see clustering of symptoms across diagnostic categories. Genetic information sometimes doesn't align with the categories that we've been using. There's other diagnoses that are hardly used at all, and we have not otherwise specified tags when symptoms don't quite meet criteria for our existing diagnoses, and when we end up using the tag too often, it tells us that we're not capturing the diagnoses we should. So it was time to update, and it was a very long process T. Began many years ago, first establishing how the task would be approached by the American psychiatric association, and then identifying the people best to write it. It was important to have people who were not only expert in the field but also not encumbered by conflicts of interest with pharmaceutical companies or other entities that might compromise or make their involvement appear to be compromised. And then those leaders assembled the panels of experts, workgroups, who were assigned to tackle individual categories of psychiatric conditions. And pour over tremendous amounts of scientific information and research regarding the accuracy of diagnoses that we're using now, and how they can be improved, which ones should be eliminated, and which new ones did we need to better be able to help our patients. CAVANAUGH: What work did you do on the DSM5? MURPHY: Well, very little. I was a field trial participant which meant as a draft, one of the drafts of DSM5 was developed, put out to testing among several academic organizations, extensive testing using new draft criteria, but also thousands of clinicians like myself working out of offices had the chance to apply the new criteria to patients in our clinical practice and report on how that experience went. And information from those field trials helped establish the validity and potential accuracy of the new diagnostic criteria. CAVANAUGH: Now, doctor Murphy, you must have already seen some of the criticisms of the new DSM5. I want to take you through a couple of them. Why for instance do you think what some psychiatric professionals refer to as common grief, it now can be diagnosed as major depressive disorder. MURPHY: Well, certainly the vast majority of people who experience a loss answer symptoms of grieving which do not reflect illness per se and do not need treatment, very often, any more than the love and support that the grieving individual gets from friends or from a support group. But some individuals after a loss develop much more severe symptoms. They lose the ability to experience pleasure, their interests disappear, they lose their ability to function in a normal way in their lives. And this continues on for many weeks, sometimes months, and it is evident that that kind of grieve is a special circumstance that is difficult to distinguish and in fact may not be distinguishable from a major depressive episode. So drawing attention to that makes it clear that there are some grieving individuals whose symptoms are so severe that they really require treatment. CAVANAUGH: Another now classification in this DSM is binge eating disorder, characterized by excessive eating at least 12 styles in three months. Considering there are four weekends in each of those months, a lot of people might qualify for that diagnosis. MURPHY: Well, the eating needs to be accompanied by significant clinical distress, a sense. Loss of control. I think we'll have to wait and see exactly what the criteria for the new condition look like, but I'm not an expert in eating disorders. But I understand from those who have studied it, that it's clear that there is a subset of people whose lives are very much impaired by their inability to control their bingeing. CAVANAUGH: One area in which the classification of disorders has contracted instead of expanded is the definition of certain autistic disorders. And Nicole, I want to bring you into the conversation. Asperger's syndrome is being incorporated into a new autistic spectrum disorder. Are you clear about what that means? HOPE-MOORE: As far as the autism society of San Diego goes, we are -- just want to continue, as it continues to evolve, we're going to just continue to develop and support the families with children on the spectrum disorder. We do not differentiate between either or, depending on the level of severity and the impact the autism has on the individual. But our goal is mission within San Diego County is to continue to support the families and the individuals on the spectrum. So to further address your question, are with the new changes in DSM and Asperger's no longer falling under that umbrella, we'll just continue to support the families and individuals as everything evolves. CAVANAUGH: Now, I heard however you're getting some e-mails. This is concern in the community. HOPE-MOORE: Well, they're just concerned about how these changes are going to affect how they access services through their different regional centers and insurance. Those types of things we do not have any direct control over. Our purpose is just to support the families on out there and get them access to the community organizations, research, and agencies. But parents are very concerned. We have a conference coming up in February, it's a special advocacy focused conference, and we just want parents to become as educated as possible, to stay abreast of the trends that are taking place so they can make sure their children are having their needs met within the education and healthcare industries. CAVANAUGH: Doctor Murphy, from what you know about this new classification of autism, of Asperger's syndrome basically being incorporated into this new autism spectrum disorder category, has that been translated by the media very well? I think that there is a lot of undue concern among parents because of this, simply because of the headlines that have come out of this. MURPHY: Well, just to educate your listeners a bit on this, the spectrum has been until now divided into three primary syndromes. There's autism, and then Asperger's disorder, and another condition called pervasive developmental disorder. And it has been accepted, I think for sometime, that Asperger's was related to autism, that individuals with Asperger's disorder, although generally functioning at a much higher level, many individuals with Asperger's have jobs, careers, are involved in the arts, they get married, have families. But they also have had symptoms which mirror some of the symptoms in autism disorder. And what the workgroup found as they studied this, in fact they referred to a mountain of evidence that there is really no real scientific difference between these disorders except for the fact that individuals with Asperger's disorder have very high functioning autism. They are brighter, their symptoms are milder, and they have much higher rates of success in various spheres of their lives. CAVANAUGH: Right. MURPHY: But it's basically the same condition. So the workgroup recommended that the conditions be described as autism spectrum disorder. And the reason it's going to be very helpful I think for families and individuals with these conditions is that now it's more obvious that treatment for one might help treatment for another one of the conditions. For example, we have some FDA approved medications that are approved for treating autism, but there are no FDA approved treatments for Asperger's disorder. I'm talking about medications. CAVANAUGH: Sure. MURPHY: Now that they're in the same condition, doctors won't be in the situation of having to use these medications offlabel for someone with Asperger's disorder which creates concerns and liabilities for a physician, and worries in family members. So I think it will improve treatment and also improve access to special services in schools and elsewhere. CAVANAUGH: However, and to be clear, this DSM basically says everyone who has gotten a diagnosis of Asperger's, that diagnosis is going to be retained. However, for new diagnoses, the DSM working panel estimates this change will eventually shrink autism diagnoses by about 10%. Is that a good thing? MURPHY: Well, it gets at another problem. There is some lack of clear boundaries of when is a person autistic or when do they have Asperger's versus when are they a bit socially awkward but should not be considered to be in the spectrum. And studies would indicate that the same individual assessed by experts in autism, in Boston, Los Angeles, San Diego, and Chicago, there would not necessarily be agreement into who has autism and who doesn't. They are likely to get a different diagnosis in each of these localities. So the hope is that with the new criteria, we're going to have much more consistency about who is diagnosed with an autistic spectrum disorder and who is not. So that's the hope, and we'll have to see if that works out. CAVANAUGH: Nicole, you mentioned that there's going to be a conference coming up early next year. HOPE-MOORE: Yes. CAVANAUGH: Would you imagine that this is going to be one of the topics of conversation, and perhaps organizations such as yours and schools are going to have to rethink how special services are assigned in the future if indeed the number of autism diagnoses shrinks? HOPE-MOORE: Well, the conference that takes place on February 1st is going to target more so special education advocacy. It's going to help education the parents and professionals, and how to better advocate for their children and clients as well as the students. I think from the perspective of the San Diego autism society, it's just going to be important that those individuals who care for or service individuals on the spectrum, that they are capable of accessing the resources available to them, aware of the trends, aware of the therapies or medications that may or may not help. And it's going to be really important to just stay abreast. CAVANAUGH: Of the new developments HOPE-MOORE: Yes. With autism, it's constantly changing and evolve,s and what's been going early on in the beginning of the emergence of diagnoses, now with the new DSM5, I believe they're going to be looking a little bit closer at some of the characteristics that children display. And that's why it's going to be so important for the educators to be there as well, because there may be a need to shift the educational approach and how special education teachers are addressing the needs of the children in the classroom. So education is key for everything, so it's just going to be so important that everyone should stay abreast of everything that's taking place. CAVANAUGH: Doctor Murphy, do new editions of the DSM usually provoke controversy? MURPHY: Not necessarily. But there's always some controversy. We're hoping that by educating the public properly on what's improved in the new volume that the controversies will die down. I would tell you that many of the most controversial proposals for DSM5 were cut back or muted. Overall it's a fairly conservative document in terms of making major changes. I'd also just want to make you all aware that San Diego psychiatric society is sponsoring in cooperation with the American psychiatric association a 2-day conference just on the DSM5 that's going to be held on June 8th and 9th at the La Jolla Hyatt. So we're hoping that through events like this, we'll get the word out, and it'll be widely accepted. CAVANAUGH: That's fascinating. We will follow up on that. Thank you very much. I've been speaking with doctor Timothy Murphy with the San Diego psychiatric society, and Nicole Hope Moore, president elect of the San Diego autism society. Thank you both. HOPE-MOORE: Thank you. MURPHY: Thank you.
The fifth edition of the Diagnostic and Statistical Manual (or DSM-5) compiled by the American Psychiatric Association was released to the public last weekend. And it's causing quite a bit of controversy.
The new edition of this manual changes the designation of some autistic disorders, and some critics say it changes normal activities like overeating and grief into new illnesses of the mind.
Dr. Timothy Murphy, a member of the San Diego Psychiatric Society and president-elect of the California Psychiatric Association, told KPBS that it's been 19 years since the previous edition was released.
"Over time, problems emerge," he said. "We see clustering of symptoms across diagnostic categories. Genetic information sometimes doesn't align with the categories that we've been using. There's other diagnoses that are hardly used at all, and we have not otherwise specified tags when symptoms don't quite meet criteria for our existing diagnoses, and when we end up using the tag too often, it tells us that we're not capturing the diagnoses we should.
"So it was time to update, and it was a very long process," he added. "It began many years ago, first establishing how the task would be approached by the American Psychiatric Association, and then identifying the people best to write it. It was important to have people who were not only experts in the field but also not encumbered by conflicts of interest with pharmaceutical companies or other entities that might compromise or make their involvement appear to be compromised."
Grief could now be classified as a depressive disorder using the manual, which some say is too extreme.
Murphy said some people who experience a loss have symptoms of grieving that do not reflect an illness, and those people do not need treatment.
"But some individuals after a loss develop much more severe symptoms," he said. "They lose the ability to experience pleasure, their interests disappear, they lose their ability to function in a normal way in their lives. And this continues on for many weeks, sometimes months, and it is evident that that kind of grief is a special circumstance that is difficult to distinguish and in fact may not be distinguishable from a major depressive episode. So drawing attention to that makes it clear that there are some grieving individuals whose symptoms are so severe that they really require treatment."
The new manual also makes binge eating disorder a recognized mental disorder. It is defined as excessive eating at least 12 times in three months.
Murphy said to meet the definition, the eating needs to be accompanied by significant clinical distress.
"I understand from those who have studied it, that it's clear that there is a subset of people whose lives are very much impaired by their inability to control their bingeing," he said.
Asperger's syndrome is also being incorporated into a new autistic spectrum disorder in the new manual. Nicole Hope-Moore, president-elect of the Autism Society of San Diego, told KPBS the change has caused concern in the local autism community.
"They're just concerned about how these changes are going to affect how they access services through their different regional centers and insurance," she said. "Those types of things we do not have any direct control over. Our purpose is just to support the families out there and get them access to the community organizations, research and agencies. But parents are very concerned."
Murphy said until now, the autism spectrum has been divided into three primary syndromes: autism, Asperger's disorder and pervasive developmental disorder.
"It has been accepted, I think for sometime, that Asperger's was related to autism, that individuals with Asperger's disorder, although generally functioning at a much higher level, many individuals with Asperger's have jobs, careers, are involved in the arts, they get married, have families," he said. "But they also have had symptoms which mirror some of the symptoms in autism disorder. And what the workgroup found as they studied this, in fact they referred to a mountain of evidence that there is really no real scientific difference between these disorders except for the fact that individuals with Asperger's disorder have very high functioning autism. They are brighter, their symptoms are milder, and they have much higher rates of success in various spheres of their lives."
