Saturday, October 12, 2013

DSM 5 Total Diagnoses Revealed

As any reader of this blog can recall one of my foci is to expose the anti DSM 5 rhetoric for what is was.  One the the main points by DSM detractors was diagnostic proliferation or more total diagnoses.  This implies more diagnoses, more prescriptions, and more money for psychiatrists and pharmaceutical companies.  Another spin was that it was the intent of organized psychiatry to "pathologize" the population.  I put up a table on this issue in a previous post and at that time did not have the final number of diagnoses.  As of today I have the final number and it is 157.  According to the presenter that means that a total of 15 diagnoses were eliminated from DSM-IV to DSM 5.  The total diagnoses in DSM 5 did not increase as the detractors predicted - they decreased by 15.

I was at a conference today put on by the University of Wisconsin Department of Psychiatry entitled Annual Update and Advances In Psychiatry.  The Introduction by Art Walaszek, MD acknowledged that this was the first in a series that replaces a long tradition of courses run by John H. Greist, MD and James W. Jefferson, MD: "Jeff Jefferson and John Greist ran this conference for 31 years."  That is an amazing track record and record of achievement and a contribution to psychiatry in the Midwest.  I don't know of many psychiatrists who were not aware of this conference with the alliterative titles like:  "Quaffing Quanta of Quality from Quick Witted Quinessentialists" or the Door County Course they regularly taught.  They have been a model of scholarship and professionalism and continue to be.

The first speaker today was Alan Schatzberg, MD.  He posted the information about the total diagnostic categories in DSM 5 an other important changes and how they occurred.  Per my previous post about the DSM 5 lectures by Jon Grant, MD the DSM 5 effort was outlined in addition to some critical information on how stigma affects psychiatric diagnosis.  For example, when the DSM 5 work group wanted to add mild neurocognitive disorder a well known historian of psychiatry came out and said it would add countless people who had normal memory impairment associated with aging.  When neurologists added mild cognitive disorder to their diagnostic nomenclature (an equivalent diagnosis) no such claims were made about neurologists.  In terms of the effort, Dr. Schatzberg pointed out that there were 13 conferences from 2003-2008 that produced 10 monographs and over 200 journal articles.

Dr. Schatzberg and his colleagues presented a ton of information today on what really happened with DSM 5 development.  I will try to summarize and post additional comments when I can post from a more user friendly computer.  I wanted to keep the post more on the scientific and debunk another common refrain from the naysayers before the DSM 5 was printed.  That involved the so called "bereavement exclusion" that basically says that a person cannot be diagnosed with major depression if they are seen during an episode of grief.  One question that was never brought up in the popular press "Where did this convention came into the diagnostic criteria in the first place?"  I quoted a text from about the same time (see third from last paragraph) that makes this convention seem even more arbitrary.  It turns out the original bereavement exclusion began in DSM-III not from any research basis but from convention that was subjectively determined by the authors of DSM-III.  Contrast that with the research done by Zisook,  et al. You would think that some of the self proclaimed level headed skeptics out there would have referred to this critical paper on the issue rather than speculative attacks on the field.  Incorporating these scientific findings was one of the reasons that the DSM was updated.

Stay tuned for more of the hard data and insider info on DSM 5.

George Dawson, MD, DFAPA

1: Zisook S, Corruble E, Duan N, Iglewicz A, Karam EG, Lanouette N, Lebowitz B, Pies R, Reynolds C, Seay K, Katherine Shear M, Simon N, Young IT. The bereavement exclusion and DSM-5. Depress Anxiety. 2012 May;29(5):425-43. doi: 10.1002/da.21927. Epub 2012 Apr 11. Review. Erratum in: Depress Anxiety. 2012 Jul;29(7):665. PubMed PMID: 22495967.

Supplementary 1:  The DSM-5 Guidebook by Donald W. Black, MD and Jon E. Grant, MD came out in March 2014.  Table 1.  (p.  xxiii) lists the total diagnoses is DSM-5 as 157 excluding "other specified and unspecified disorders". 


  1. I did a reasonably thorough review of the bereavement issue, and the Zisook study is far from the end of the story. Here's a link to my post (which includes the Zisook study):

    If you scroll down to the end, I summarize what I learned, and it really depends who you ask.

    And here's a link to the article I wrote about, by Mojtabai:

    1. Thanks for the link to your blog post. I don't think there is an end to the story - that is the nature of a scientific approach. The original post I used from Paykel's text written by Clayton makes the point that there is a selection factor. The vast majority of patients with grief don't present to psychiatrists. These days many people with grief will be treated with an antidepressant by a primary care physician based on a PHQ-9 score. They are less likely to get grief counseling or even IPT due to the decreasing amount of psychotherapy. Primary care physicians are not focused on the esoterics of DSM-5, they are trying to solve problems the best that they can. Probably the most critical information from this conference is that there was never any research to support a bereavement exclusion in DSM-III. The opinion in Paykel's text certainly did not support it. I think it is hard to fault a decision based on some evidence as opposed to a decision based on none - but that in essence was the media "debate" about the bereavement exclusion.