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 Table of Contents  
DEBATE/PERSPECTIVE/VIEWPOINT
Year : 2018  |  Volume : 34  |  Issue : 5  |  Page : 79-85

Will the DSM-5 and ICD-11 “Make-over” really make a difference to women's mental health?


Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India

Date of Web Publication20-Nov-2018

Correspondence Address:
Prof. Prabha S Chandra
Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_34_18

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  Abstract 


The recent modifications to the classificatory systems were expected to enhance the recognition of various psychiatric conditions specific to women. Several researchers and clinicians had made specific recommendations regarding four main conditions; that is, female sexual dysfunction (FSD), perinatal psychiatric disorders (PPDs), and premenstrual dysphoric disorder and eating disorders; to improve the clinical utility of these diagnoses. While FSD has undergone considerable change with its own special place outside of mental health, not all suggestions regarding PPDs were considered. A major advance in both Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) and International Classification of Diseases (ICD11) has been the inclusion of the antenatal period in PPDs, which had hitherto been left out. However, two recommendations related to PPDs-increase in the time frame of the postpartum definition and inclusion of mother–infant interaction disorders were not considered, which we believe are valuable opportunities lost. Substantial changes have been included in the clinical manifestations and course of eating disorders, based on evidence and cross-cultural differences. One condition included in ICD-11 which may help women get better treatment is complex posttraumatic stress disorder. It appears that while there are some changes that are positive, more could have been achieved for women's mental health.

Keywords: Classification, Diagnostic and Statistical Manual of Mental Disorders-5, International Classification of Diseases-11, perinatal psychiatry, women's mental health


How to cite this article:
Parameshwaran S, Chandra PS. Will the DSM-5 and ICD-11 “Make-over” really make a difference to women's mental health?. Indian J Soc Psychiatry 2018;34, Suppl S1:79-85

How to cite this URL:
Parameshwaran S, Chandra PS. Will the DSM-5 and ICD-11 “Make-over” really make a difference to women's mental health?. Indian J Soc Psychiatry [serial online] 2018 [cited 2018 Dec 11];34, Suppl S1:79-85. Available from: http://www.indjsp.org/text.asp?2018/34/5/79/245829




  Introduction Top


As early as 2010, in a special issue of the Archives of Women's Mental Health devoted to the revisions of classification, Joneson and Stewart had raised several concerns about the gender blindness of classificatory systems and the need to recognize how both biological and social constructs of sex and gender influence mental illness. They had recommended that in the updated versions of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and International Classification of Diseases (ICD11), the influence of sex and gender be recognized, women's voices and expertise be included in the working groups, and there be a greater consideration of the role of social determinants.[1]

It is now time to examine if the two classificatory systems considered the above recommendations or did we lose out on this window of opportunity for women's mental health?

We examine specific disorders related to women which have seen some change in the new classificatory systems using a critical gendered lens. Three issues are being examined:

  1. Has the new classification incorporated new scientific understanding about the condition?


    1. Will it decrease inappropriate labeling?
    2. Will it enhance detection of disorders significant for women and therefore help in developing services for women?


The conditions we examine in this paper include:

  1. Female sexual dysfunction (FSD)
  2. Perinatal psychiatric disorders (PPDs)
  3. Premenstrual dysphoric disorder (PMDD)
  4. Complex posttraumatic stress disorder (PTSD)
  5. Eating disorders
  6. Other disorders.


Female sexual dysfunction

The original classification of FSD, from the consensus panel meeting in 1998, was based on the linear model of female sexual response, which did not account for differences between men and women in their sexual response models. We now know that factors such as intimacy, relationship satisfaction, family beliefs, cultural beliefs, and early sexual experiences influence the presentation of FSD.[2],[3]

The DSM-5, published in May 2013, aimed to incorporate the newer philosophies of FSD while the World Health Organization (WHO) in the beta draft of ICD-11 specifies several changes in the section on FSDs.[4],[5],[6]

In ICD-11, sexual dysfunctions have now changed locations from “behavioral syndromes associated with physiological disturbances and physical factors” to a new section-“Conditions related to sexual health.” It remains to be seen if this change will lead to the medicalization of FSDs or will it attenuate the boundary between mental and physical disorders, reduce stigma, and encourage more women to seek treatment? Another important question is whether these changes will spur more research into pharmacology for FSD.

DSM-5 has merged “desire” and “arousal” disorders in women into one entity called the “sexual interest/arousal disorder.” The argument advanced was that they co-occur so often that they are essentially two sides of the same coin. The critics feel, however, that cooccurrence at the symptom level does not correspond to diagnostic equivalence.[7],[8] The separation of desire and arousal in women into distinct dysfunctions is also supported by genetic evidence and neuroimaging.[9],[10],[11] Research also suggests that although there is significant comorbidity between desire and arousal dysfunction, they may benefit from management that is targeted toward their distinct features.[12] There has also been much debate over elimination of the category of hypoactive sexual desire disorder (HSDD) in DSM-5, which went against the suggestions on classification of FSD by two expert panels in sexual medicine.[7],[8] ICD-11 has retained the diagnosis of HSDD. In ICD-11, the FSDs continue to be organized as desire, arousal, and orgasmic dysfunction, retaining the linear progression model. The criteria for each of these disorders have been made gender specific. However, this organization is different from DSM-5, creating challenges in harmonization.[6]

Female orgasmic disorder has been redefined as “marked delay in, marked inadequacy of, or absence of orgasm” and the phrase “following a normal sexual excitement phase” has been removed from DSM-5. ICD-11 has specified both frequency and intensity of orgasm in the description. While a detailed definition may be clinically useful, we need to remember that the word “orgasm” is easily understood when used in English but is difficult to communicate in many other languages.

“Sexual aversion” disorder and excessive sexual drive have been deleted from the DSM-5 and ICD-11. The former had limited empirical support and indicated more phobic or anxiety disorder rather than sexual disorder. Excessive sexual drive disorder among women had always been viewed with scepticism. Constructs of female sexuality have changed with time and this category deserved to be put to rest.[8]

The term “vaginismus” and “dyspareunia” were merged into “genito-pelvic pain/penetration disorder” in DSM-5 and classified under sexual pain disorders in ICD-11.[3],[7],[11] The two disorders could not be reliably differentiated and the fear of pain or fear of penetration is commonplace in clinical descriptions of vaginismus.[13]

Both ICD-11 and DSM-5 now require a minimum duration and severity criteria. The dysfunction must also cause “clinically significant distress” and not just “interpersonal difficulty.”[3],[7] The lack of a distress criterion often led to overdiagnosis of FSD and the current more stringent guidelines will avoid labelling and overdiagnosis of what is a common complaint in women due to interpersonal and relational reasons.[6]

Cultural relevance of the new face of female sexual dysfunction

In many cultures, especially those where women are not empowered and patriarchy is prevalent, both women and health-care providers are often uncomfortable discussing sexual health issues. Societal inhibitions about female sexuality and talking about sexual difficulties combined with lack of acceptable words as well as language may hamper expression, identification, and diagnosis. The advances made in the classificatory systems in the area of FSD will not be of much use unless there is a nuanced understanding of this aspect of women's lives. ICD-11 could mention cultural, linguistic, and social factors contributing to the diagnosis of FSD. A new exclusion criterion which mentions that FSD should not be explained by a consequence of severe relationship distress (e.g., partner violence) or other significant stressor is a positive step. A similar purpose is served in DSM-5 by the inclusion of “associated features” that mention partner and relationship issues, vulnerability (poor body image; sexual or emotional abuse), psychiatric comorbidity, stressors, cultural and religious factors (e.g., inhibitions related to sexual pleasure; attitudes toward sexuality), and medical factors [Table 1].[4],[6]
Table 1: Female sexual dysfunction in the new classificatory systems

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Perinatal psychiatric disorders

In a special issue of a Women's Mental Health Journal, several perinatal psychiatrists had recommended changes in both the ICD and DSM to enhance the early detection of PPDs and to make it more clinically relevant and in keeping with advancement in science and policy.[14] These include extending the time frame of the onset qualifier to impact all mood disorders occurring in the first 6 months postpartum, rather than a restrictive time frame of 4 or 6 weeks and specifically mentioning early- and late-onset disorders. The rationale for extending the postpartum-onset specifier to 6 months for mood disorders was that it would enhance recognition and treatment of mental health problems in the first year after childbirth since it has significant impact on the mother and infant. The 6-week qualifier for both depression and psychoses could be used mainly for biological research. Removal of the “disorders associated with physiological disturbances and physical factors” category and the “not classified” descriptor in the ICD-10 would bring postpartum disorders into the mainstream, more in line with the DSM.

Other recommendations made in the special issue of Women's Mental Health Journal regarding PPD were as follows: inclusion of a code for mother–infant interaction difficulties to help clinicians and policy makers consider the impact of maternal mental illness on the infant; inclusion of pregnancy as an onset specifier; and the use of the word “perinatal” rather than “postpartum”.[14] It was also recommended that childbirth-related trauma be included in the list of trauma for PTSD. This was considered important for better recognition of the disorder and better education regarding obstetric care.[15] Some changes have been made to PPDs in both DSM and ICD systems, but they are obviously not enough. A major positive change has been the inclusion of pregnancy as an onset specifier/qualifier for several conditions both in DSM-5 and ICD-11. However, disappointingly, the duration criterion remains the same (4–6 weeks postpartum). Mother–infant interaction disorders have not been included (even as a category requiring further research) and childbirth trauma does not appear in the section on PTSD. ICD-11 continues to have a category of “mental or behavioral disorders associated with pregnancy, childbirth, and the puerperium, not elsewhere classified” with or without psychosis. This should have ideally been removed and replaced by a perinatal qualifier in all psychotic, mood, and anxiety disorders like in DSM-5, for better diagnosis, identification, and management [Table 2].[4],[5],[6]
Table 2: Comparison between the classificatory systems for perinatal psychiatric disorders

Click here to view


Premenstrual dysphoric disorder

Premenstrual mood or behavior change was officially categorized as a psychiatric disorder in DSM-IV. Critics argued that premenstrual changes were a normal part of women's experience. There was concern that “PMDD” or “PMS” was a Western cultural construct and women in Eastern societies reported more physical symptoms and rarely reported negative moods. In fact, some authors even termed PMS a culture-bound syndrome.[16],[17] PMDD has found a place both in DSM-5 and the ICD-11 draft and is included under depressive disorders. Another change in the DSM-5 is the inclusion of “provisional” if the diagnosis was made retrospectively; with the need for a prospective assessment of two symptomatic cycles to confirm the diagnosis.[4]

The argument for moving PMDD to a full-fledged diagnosis in the DSM-5 and ICD-11 is that clinical as well as epidemiological studies suggest that some women may experience severe mood symptoms that begin during the luteal phase and terminate with the onset of menses, often leading to impaired functioning in various domains, which improves with treatment.[18],[19] Without clear diagnostic boundaries, these symptoms may be dismissed or mistaken for a mood disorder. Having more stringent criteria will ensure that overdiagnosis does not occur.[20] This is one condition which definitely needs more research to ensure that medicalization of menstruation and the menstrual cycle does not happen and women are not unnecessarily labeled with a diagnosis of a mental disorder.

Complex posttraumatic stress disorder-will it help women with trauma histories get better care?

Gender differences are evident in several studies done on PTSD, which is known to be twice as common in women. Sexual abuse and interpersonal violence, which carry among the highest risk of producing PTSD, are much commoner in women. Women are also more likely to present with internalizing symptoms as opposed to men who more often report using substances.[21]

There has always been a question about the ability of the standard DSM definition of PTSD to capture the full range of trauma-related psychopathology. Critics have argued that it misses a distinct but important clinical syndrome identified originally in survivors of prolonged childhood sexual trauma, termed complex PTSD.[4] Complex PTSD is characterized by problems in the domains of interpersonal relationships, somatization, affect regulation, dissociation, and sense of self. A variation of this construct, called “disorders of extreme stress, not otherwise specified,” was proposed for inclusion in DSM-IV. However, it was rejected due to concern about its overlap with PTSD and borderline personality disorder.[5],[6]

DSM-5 does not have this category but has a new dissociative subtype of PTSD. Pervasive negative mood, distorted negative cognitions, and reckless behavior, which may align with some conceptualizations of complex PTSD, have been added to the DSM-5 criteria.[7] ICD-11 has, however, proposed a new grouping termed “disorders specifically associated with stress,” which would include a narrowly defined PTSD diagnosis and a new complex PTSD diagnosis, conditional on the presence of PTSD.

Complex PTSD has been proposed as a diagnosis for capturing the cluster of symptoms observed in survivors of prolonged trauma.[8] A study by Roth et al. suggested that sexually abused women, especially those who also experienced physical abuse, had a higher risk of developing complex PTSD.[9] Complex PTSD symptoms manifest as alterations in psychobiological processes associated with affect regulation (impulsivity, self-harm), attention and consciousness (dissociation), self-perception (shame, guilt), relationships with others (mistrust), somatic functioning (psychosomatic pain), and meaning in life (despair at future).[10],[11],[12] While it is to be seen how often this diagnosis will be made and accepted by clinicians, the fact that it is recognized and described, will ensure that women who are often victims of multiple trauma, are not labeled as personality disorders and are also able to access more trauma-based interventions.

Eating disorders

ICD-11 and DSM-5 have introduced several changes in the classification of eating disorders based on the available evidence.

Anorexia nervosa (AN) has been redefined and terms such as denial, refusal, self-induced, which lack evidence and also convey a paternalistic attitude have been removed. ICD-11 guidelines focus on clearly observable behaviors and cognitions. ICD-11 provides a definition of “a significantly low body weight” for adults (body mass index <18.5 kg/m2), while DSM-5 mentions “restriction of energy intake relative to requirements” as a core aspect of the disorder. The provision of thresholds will prove important in increasing the diagnostic reliability. Both ICD-11 and DSM-5 have moved away from fatphobia as a necessary criterion for the diagnosis, by including engagement in persistent behavior that interferes with weight gain as an alternative. There is evidence that non-Western persons are less likely to express fear of gaining weight, making the new criterion more culture neutral and it will likely improve the cross-cultural validity of the disorder. ICD-11 now also avoids reference to the symptoms of starvation and associated endocrine disturbances. Symptoms of starvation separate females with AN from constitutionally underweight females. In light of attempts to define biological markers for mental disorders, the nonrecognition of endocrine alterations associated with AN (e.g., hypoleptinemia) represents a step backward.[22]

Binge eating disorder is a separate category in ICD-11. The recognition of this disorder would help avoid the overuse of the “eating disorder: Unspecified” diagnosis, which was considered to be heterogeneous and unhelpful. Avoidant-restrictive food intake disorder, a new diagnosis in ICD-11 may be relevant for women with restricted eating patterns in pregnancy leading to problems in weight gain and nutritional deficiency [Table 3].[23]
Table 3: Major changes in eating disorders from International Classification of Diseases-10 to International Classification of Diseases-11

Click here to view


Other changes

Mixed anxiety-depressive disorder, a common condition in primary care,[24] has been excluded from DSM-5. Instead, a specifier “with anxious distress” has been added to depressive and bipolar disorders. ICD-11, however, proposes to include mixed depressive and anxiety disorder, under depressive disorders. Including this condition may help patients (including women) get early treatment and prevent exacerbations to more serious psychiatric disorders.[25] It has special implications for women because perinatal depression is often associated with anxiety symptoms and frequently justifies a mixed anxiety and depression diagnosis.

A potential limitation of ICD-11 regarding conditions relevant to women is that fear of complications related to pregnancy, and fear of breast and genital diseases have not been recognized under mental and behavioral disorders. This would decrease recognition of and intervention for these conditions.


  Will the ICD-11 Influence Mental Health Care for Women in Low and Middle Income Countries? Top


Most mental health problems that women in LAMI countries face are similar to those which women face globally. However, the context is different. There are higher rates of anxiety, depression, and somatic symptoms; limited psychiatric services; poor availability of psychological treatments; and lack of integration of maternal and mental health services. Lack of sex disaggregated data hampers planning and prioritization of health services, and as a consequence affects budget allocation. The WHO recommends comprehensive gender analyses and the need for integrating gender-relevant indicators in the existing national health information systems, to enhance the understanding of mental health problems among women.[26] In this context, the ICD-11 does not come up to expectations on some counts. PPDs should have got more importance both as qualifiers and with respect to time frame. It is ironical that PMDD a less common disorder in the LAMI setting is better recognized compared to perinatal depression or anxiety which are much more common and have the potential to cause significant disability. For policy decisions and resource allocation, using a time frame that includes “pregnancy and 1 year after childbirth” is important as has been shown in several studies from LAMI countries.[14] It would have also been important to mention that depression in women often manifests as physical symptoms that are medically unexplained (such as pain or vaginal discharge) and women may not meet all criteria for classical depression, hence leading to lower rates of detection. The inclusion of complex PTSD, however, is a welcome move for identifying women in conflict zones and those undergoing multiple trauma including intimate partner violence.


  Conclusions Top


Will all the above changes or lack of desired changes make a difference to women's mental health? We think it will definitely have some impact. The recognition of FSDs may increase but being removed from the section on mental health in ICD-11, may result in a new category of professionals: Sexual health experts who will take over their care. While this will be less stigmatizing for women, it may also medicalize these conditions more. The impact of trauma such as partner violence and sexual trauma may be recognized more; however, childbirth-related trauma may continue to be underrecognized. In the case of PPDs clearly more could have been done. Including pregnancy as a qualifier is a positive step but restricting the time frame limits its utility. We hope that the final version of the ICD-11 will incorporate some of the suggestions made by researchers in the field and attempt to discuss conditions with a gendered lens.

In conclusion, while quoting Bob Marley's song- “No Woman, No Cry” for the positive changes in the new classificatory systems, we would say that there is no reason for women to smile either!

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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