Darrel Regier, vice chair of the DSM-5 Task Force, appears a mild, unassuming researcher, slightly bemused that the release of what was intended to be a more accurate, nuanced, and rigorously researched manual has raised such an uproar—a virtual in-house outbreak of oppositional defiant disorder, and surely the most intense and widespread challenge to DSM’s legitimacy in its 62-year history. Director of the APA’s research division, he spent 25 years at NIMH heading research divisions in epidemiology, prevention, clinical research, and health-services research. Like other DSM producers and defenders, he knows perfectly well that psychiatric diagnosis is often inherently ambiguous and that the science behind the classification system isn’t all it might be. “We are faced with an interesting situation of having what are well-known deficiencies in the current diagnostic system,” he said with some understatement in a Medscape Medical News
interview. A lot of what was going into DSM-5, he admitted, “has not been tested as well as we would like. The current problem is that because the DSM has so dominated research practice for the last 30 years, nobody would even think or get funding to test different diagnostic criteria until they’re really adopted by the DSM.”
Regier regards DSM-5 not as The Law, and certainly not any kind of bible of psychiatry, but as a work in progress, “a set of scientific hypotheses that are intended to be tested and disproved if the evidence isn’t found to support them.” The manual is a “living document,” which can be regularly revised, “in much the same way as is done with software updates.”
------------------------------------------What distinguishes DSM-5 from the previous editions of the Diagnostic and Statistical Manual?Darrel Regier:
As the Task Force began to meet in preparation for working on DSM-5, the main question we considered was whether the old psychiatric diagnostic category system embodied in DSM-IV
was actually starting to hinder research by failing to reflect the latest science about psychiatric disorders. Further, in our discussions, it became clear that the emphasis on maintaining rigid boundaries between diagnoses was simply not reflecting the most up-to-date findings in genetics and family history research. For example, the research was showing that people who grew up in families with a high incidence of schizophrenia were likely to have kids with bipolar disorder, major depression, and neurodevelopmental disorders. Findings like that underscore the fact that the old idea of a strict separation of disorders and of a separate genetic vulnerability hypothesis for each separate disorder was no longer tenable given our current knowledge.
We now know that there are hundreds or thousands of genes that predispose someone to a condition like schizophrenia, and these genes interact with environmental exposures that will either turn on or turn off the gene in order to express a particular syndrome. This understanding requires us to take a different approach to the task of categorizing mental disorders. The idea that psychiatric conditions are polygenetic is something that we never imagined back in 1980 when DSM-III
was first published. So we wanted to take a more dimensional approach to diagnosis, rather than assume that psychiatric conditions all belonged in neat categories.In practice, what does this idea of “taking a more dimensional approach” to diagnosis mean?Regier:
Probably the best example would be to start with major depressive disorder, one of the most common disorders seen in clinical practice. In DSM-III
, the diagnosis of major depression involved nine criteria that include depressed mood, anhedonia or lack of interest, as well as a series of symptoms including sleep difficulties, lack of concentration, somatic concerns, and suicidal ideation. Nowhere in that set of criteria was there any mention of anxiety, even though research has established that more than 50 percent of individuals with major depression have substantial anxiety symptoms. In fact, DSM-IV
even prohibited you from considering the diagnosis of generalized anxiety disorder in the case of major depression.
While the old assumption was that anxiety disorders were completely separate from mood disorders, research has shown that depressed individuals with anxiety have a much poorer response to antidepressants and cognitive behavior therapies for depression. They also are at a higher risk for suicide. So we debated for a long time whether we should add a separate diagnosis of “anxious depression” in DSM-5, but ultimately, we decided against it because we didn’t want to reinforce the idea that there are rigid boundaries between diagnoses. Instead, we opted for symptom specifiers within various diagnoses to emphasize the wide variety of ways in which different people can experience the same psychiatric disorder. So someone can be diagnosed with major depressive disorder with a specifier of “with anxious distress” in a way that calls specific attention to the presence of anxiety symptoms without having to invent new diagnostic categories.Read the full interview with Darrel Regier, "The Two Sides of the DSM-5 Controversy: A Step in the Right Direction," in the March/April 2014 issue of Psychotherapy Networker magazine.