Mental illness is both extremely common—one in five Americans will experience a mental disorder in any given year—and extremely hard to diagnose in some cases, since no simple biological tests exist to detect them. There's no blood test for, say, depression or a personality disorder; no scan that can reveal attention-deficit hyperactivity disorder (ADHD). Instead, a clinician must rely solely on a patient's symptoms and observation of his or her behavior to reach a diagnosis.
Guiding mental health professionals through that process is the "bible" of mental health: the Diagnostic and Statistical Manual of Mental Disorders, or DSM, published by the American Psychiatric Association. First released in 1952, it's undergone numerous revisions over the years, often accompanied by intense debate over which conditions should be included and how they should be classified. Those decisions can have profound implications—determining, for example, whether a person will be able to get insurance to cover their psychiatric visits, or whether a child will qualify for special services at school.
Perhaps no edition of the DSM has received more scrutiny or engendered more debate than the most recent one, DSM-5, released in 2013. With expanded definitions of many illnesses and 15 new ones, the new manual has been criticized by some experts as unnecessarily broadening the definition of what constitutes mental illness—pathologizing normal, if unpleasant, behaviors such as temper tantrums and grief and turning them into diagnosable, insurance-reimbursible disorders. Supporters counter that the changes bring the manual more in line with current research and clinical experience, and point out that the total number of disorders in the new manual—157—is no higher than in its four predecessors (and in fact is lower than in previous edition, DSM-IV).
Here are four new or updated conditions in the DSM-5 that have been particularly controversial. It's worth familiarizing yourself with them, in the event that you or someone you care about is diagnosed with one.
1. All in your head? Somatic symptom disorder
How it's defined: People diagnosed with this condition (previously somatization disorder) are plagued by physical symptoms—stomach pain, mysterious aches—that can’t be explained by a medical diagnosis and that cause them significant distress, disability, or both.
What changed: In DSM-IV, a person had to have a long, complex list of unexplained physical symptoms to qualify for the diagnosis. DSM-5 requires only one unexplained symptom.
The rationale: The DSM-5 task force felt that the stricter criteria in the previous manual made it difficult to help patients with chronically mysterious medical complaints, according to a fact sheet on the disorder. The DSM-IV criteria also depended too much on physical symptoms rather than the “abnormal thoughts, feelings and behaviors” caused by those symptoms.
Why it’s controversial: Some experts and patient advocates worry that the new definition makes it too easy for a doctor to label someone as mentally ill if they have even a single unexplained physical symptom. This could particularly affect patients with hard-to-pin-down ailments like fibromyalgia and chronic fatigue syndrome. “Patient groups hate this,” says psychiatrist Allen Frances, MD, a professor emeritus at Duke University and DSM-IV task force chair who has been a vocal critic of the DSM-5. “The risk is that people who have unexplained medical problems, instead of receiving a good medical workup, will be shunted off to a psychiatrist.”
See the DSM fact sheet on somatic symptom disorder.
2. From lost keys to impending Alzheimer’s: Mild neurocognitive disorder
How it's defined: A possible precursor to Alzheimer’s disease, with symptoms including cognitive decline, memory loss, and confusion that are noticeable and distressing. The level of decline “goes beyond normal issues of aging,” is usually observable by other people, and requires the person to make accommodations and use compensatory strategies to stay independent and perform activities of daily living.
What changed: The condition didn’t exist in DSM-IV.
The rationale: Identifying neurocognitive changes as early as possible may allow interventions to be more effective, according to a task force fact sheet.
Why it’s controversial: There’s no reliable way to tell whether memory blips or other cognitive difficulties that arise as people get older are a result of normal aging—in which case they’ll worsen only gradually—or a sign of impending Alzheimer’s. Indeed, a large number of people with mild age-related cognitive decline never go on to develop the disease—so the new diagnosis in theory could lead to unnecessary testing and overprescribing of medications—plus a lot of stressed patients and families, especially since there remains no effective treatment for the disease.
See the DSM fact sheet on mild neurocognitive disorder.
3. Tantrums turned mental illness: Disruptive mood dysregulation disorder
How it’s defined: The key symptom is temper tantrums at least three times a week in children ages 6 to 18, with the volume and intensity turned way up. Between tantrums, children with the condition tend to be angry and irritable.
What changed: The diagnosis is a new one, although some symptoms overlap with those of ADHD and childhood bipolar disorder.
The rationale: According to the APA, the new disorder was added to “address concerns about potential overdiagnosis and overtreatment of bipolar disorder in children.” (Indeed, diagnoses of bipolar disorder in children and teens increased 40-fold in the decade between 1994-1995 and 2002-2003 alone, according to an NIH report.) The theory was that the new diagnosis would offer a way to identify and help children with out-of-control rage without misclassifying them as bipolar.
Why it’s controversial: Frances and other critics argue that the new diagnosis makes it too easy to label any child prone to tantrums as mentally ill, exposing them not only to stigma but to powerful and potentially dangerous medications.
See the DSM fact sheet on disruptive mood dysregulation disorder.
4. One nation on Adderall? Attention Deficit/Hyperactivity Disorder (ADHD)
How it’s defined: ADHD is a neurodevelopmental disorder marked by persistent inattention, hyperactive or impulsive behavior, or both.
What changed: In DSM-IV, ADHD could only be diagnosed if certain symptoms appeared before age 7; now the threshold is age 12. The new DSM also includes examples to illustrate the different ways ADHD might present in adults versus children and older adolescents.
The rationale: The updated criteria were intended to address adults affected by ADHD and ensure they are able to get care when needed, according to a fact sheet on the diagnosis.
Why it’s controversial: Critics argue that ADHD is already overdiagnosed, and that broadening the diagnosis will make it easier for adults seeking a performance boost to get a prescription for stimulant drugs such as dextroamphetamine(Adderall) and methylphenidate (Ritalin).
See the DSM fact sheet on ADHD.