DSM-5 a fost aprobat. Controversele continuă

La începutul acestei luni, potrivit comunicatului preşedintelui Asociaţiei Psihiatrice Americane, Dilip Jeste, pe care îl puteţi citi mai jos, a fost finalizat DSM-5 – cea de-a cincea ediţie a celebrului Diagnostic and Statistical Manual of Mental Disorders.

A Message From APA President Dilip Jeste, M.D., on DSM-5 

December 1, 2012 

I am pleased to announce that DSM-5 has just been approved by APA’s Board of Trustees.
Getting to the finish line has taken a decade of arduous work and tens of thousands of pro-bono
hours from more than 1,500 experts in psychiatry, psychology, social work, psychiatric nursing,
pediatrics, neurology, and other related fields from 39 countries. We look forward to the book’s
publication next May. 

The goal of the DSM-5 process has been to develop a scientifically based manual of psychiatric
diagnosis that is useful for clinicians and our patients. APA’s interest in developing DSM dates
back to the organization’s inception in 1844, when one of its original missions was to gather
statistics on the prevalence of mental illness. In 1917, the Association officially adopted the first
system for uniform statistical reporting called the Statistical Manual for the Use of Hospitals for
Mental Diseases, which was adopted successfully by mental hospitals throughout the country. It
was expanded into the first Diagnostic and Statistical Manual (DSM) in 1952 and first revised
(DSM-II) in 1968. Like the rest of the field in that era, these first two versions were substantially
influenced by psychoanalytic theories. 

With advances in clinical and scientific knowledge, changes in diagnostic systems are inevitable.
The World Health Organization’s International Classification of Diseases (ICD)—the standard
diagnostic tool for epidemiology, health management, and clinical care used around the world,
which covers all medical diagnoses—has been through 10 editions since the late 1800s and is
now preparing its 11th edition, due in 2015. Likewise, DSM has undergone changes to take into
account progress in our understanding of mental illnesses. DSM-III, published in 1980 under the
leadership of Dr. Robert Spitzer, and DSM-IV, published in 1994 under the leadership of Dr.
Allen Frances, represented the state of science of psychiatry at those times and significantly
advanced the field.
In the two decades since the publication of DSM-IV, we have witnessed a wealth of new studies
on epidemiology, neurobiology, psychopathology, and treatment of various mental illnesses. So,
it was time for APA to consider making necessary modifications in the diagnostic categories and
criteria based on new scientific evidence. But there were, of course, challenges inherent in
revising an established diagnostic system. 

The primary criterion for any diagnostic revisions should be strictly scientific evidence.
However, there are sometimes differences of opinion among scientific experts. At present, most
psychiatric disorders lack validated diagnostic biomarkers, and although considerable advances
are being made in the arena of neurobiology, psychiatric diagnoses are still mostly based on
clinician assessment.
Also, there are unintended consequences of psychiatric diagnosis. Some arise from the
unfortunate social stigma and discrimination in getting jobs or even obtaining health insurance
(notwithstanding the mental health parity law) associated with a psychiatric illness. There is also
the double-edged sword of underdiagnosis and overdiagnosis. Narrowing diagnostic criteria may
be blamed for excluding some patients from insurance coverage and needed services, while
expanded efforts to diagnose (and treat) patients in the early stages of illness to prevent its
chronicity are sometimes criticized for increasing its prevalence and potentially expanding the
market for the pharmaceutical industry. (It should be noted, however, that DSM is not a treatment
manual and that diagnosis does not equate to a need for pharmacotherapy.) 

APA has carefully sought to balance the benefits of the latest scientific evidence with the risks of
changing diagnostic categories and criteria. We realize that, given conflicting views among
different stakeholders, there will be inevitable disagreements about some of the proposals—
whether they involve retaining the traditional DSM-IV criteria or modifying them. 

The process of developing DSM-5 began in earnest in 2006, when APA appointed Dr. David
Kupfer as chair and Dr. Darrel Regier as vice chair of the task force to oversee the development
of DSM-5. The task force included the chairs of 13 diagnostic work groups, who scrutinized the
research and literature base, analyzed the findings of field trials, reviewed public comments, and
wrote the content for specific disorder categories within DSM-5. To ensure transparency and
reduce industry-related conflicts of interest, APA instituted a strict policy that all task force and
work group members had to make open disclosures and restrict their income from industry. In
fact, the vast majority of the task force and work group members had no financial relationship
with industry. 

To obtain independent reviews of the work groups’ diagnostic proposals, the APA Board of
Trustees appointed several review committees. These included the Scientific Review Committee
(co-chaired by Drs. Ken Kendler and Robert Freeman), Clinical and Public Health Committee
(co-chaired by Drs. Jack McIntyre and Joel Yager), and APA Assembly Committee (chaired by
Dr. Glenn Martin). Additionally, there was a forensic review by members of the Council on
Psychiatry and Law. Drs. Paul Appelbaum and Michael First were consultants on forensic issues
and criteria/public comments, respectively. Reviews by all these groups were coordinated in
meetings of the Summit Group, which included the task force and review committee co-chairs
and consultants along with members of the Executive Committee of the Board of Trustees. 

There has been much more public interest and media scrutiny of DSM-5 than any previous
revisions. This reflects greater public awareness and media interest in mental illness, as well as
widespread use of the Internet and social media. To facilitate this transparent process, APA
created a Web site (www.dsm5.org) where preliminary draft revisions were available for the
public to examine, critique, and comment on. More than 13,000 Web site comments and 12,000
additional comments from e-mails, letters, and other forms of communication were received.
Members of the DSM-5 work groups reviewed the feedback submitted to the Web site and,
where appropriate, made modifications in their proposed diagnostic criteria. 

We believe that DSM-5 reflects our best scientific understanding of psychiatric disorders and
will optimally serve clinical and public health needs. Our hope is that the DSM-5 will lead to
more accurate diagnoses, better access to mental health services, and improved patient outcomes.

• Secţiunea 1 va consta într-o introducere şi în trecerea în revistă a actualizărilor manualului. 
• Secţiunea 2 va face schiţa categoriilor diagnostice, în cadrul unei organizări revizuite pe capitole.  
• Secţiunea 3 va arăta care noţiuni necesită în continuare să fie cercetate înainte de a fi considerate tulburări, va panorama concepte culturale despre distress şi va cuprinde şi alte informaţii.  

DSM-5 îi urmează ediţiei din 1994, DSM-IV, şi, aşa cum precizează comunicatul de mai sus al preşedintelui APA, se fundează pe contribuţiile a peste 1 500 de specialişti în toate domeniile medicinei, din 39 de ţări. Această ediţie va aduce modificări substanţiale tabloului nosologic psihiatric, una dintre cele mai importante (şi demult anticipată) constând în statuarea unei tulburări autiste, care înlocuieşte tulburarea de spectru autist – ceea ce înseamnă că Sindromul Asperger, o formă mai puţin severă de autism, va înceta să mai existe ca entitate diagnostică şi va fi inclusă în categoria mai largă indicată (schimbarea provoacă deja îngrijorare organizaţiilor preocupate de autism, care se tem că unii autişti nu vor mai fi luaţi în calcul la acoperirea costurilor de tratament de către asigurări). 

Astfel de schimbări radicale au stârnit, de altfel, mai multe controverse în lumea ştiinţifică şi chiar un mare scandal, ce durează de ani de zile – termenele de concepţie şi de redactare ale DSM-5 au fost, şi ele, mult amânate şi reprogramate, în urma acestor neînţelegeri (despre întreaga poveste am mai scris şi aici: „Mai întâi caii, apoi zebrele? DSM-5: un război în plină desfăşurare”). Însăşi continuarea proiectului a fost pusă în cumpănă, iar războiul s-a dezlănţuit pe mai multe fronturi, în tranşeele unor criterii şi categorii. 

Iată câteva.

iritabilitate persistentă şi episoade frecvente de accese temperamentale [sau de comportament (behaviour outbursts)] având o frecvenţă de trei sau mai multe ori săptămânal pe durata a mai mult de un an.

decesul este un factor de stres psihosocial sever care poate favoriza un episod depresiv major