Big Changes for the Psychiatrist's 'Bible'

Substantial changes are in the offing for the "psychiatrist's bible," the Diagnostic and Statistical Manual of Mental Disorders, according to a draft of the forthcoming fifth edition.

The American Psychiatric Association (APA) posted the draft of DSM-V on a special Web site, www.dsm5.org, to obtain comment from its members, other members of the mental health community, and the public.

At a telephone press briefing prior to the draft's release, members of the APA team leading the DSM revision highlighted several substantial innovations they are proposing:

Re-categorizing learning disorders, including creation of a single diagnostic category for autism and other socialization disorders, and replacing the controversial term "mental retardation" with "intellectual disability"

Eliminating "substance abuse" and "substance dependence" as disorders, to be replaced with a single "addiction and related disorders" category

Creating a "behavioral addictions" category that will include addictions to gambling but not to the Internet or sex

Offering a new assessment tool for suicide risk

Including a category of "risk syndromes" for psychosis and cognitive impairment that are intended to capture mild versions of these conditions that do not always progress to full-blown psychotic disorders or dementia, but often do

Adding a new disorder in children, "temper dysregulation with dysphoria," for persistent negative mood with bursts of rage

Revising criteria for some eating disorders, including creation of a separate "binge eating disorder" distinct from bulimia

Using "dimensional assessments" to account for severity of symptoms, especially those that appear in multiple diagnostic categories

The APA will accept comments through April 20. The work groups managing the revision will consider them and make further changes as needed to the draft, said Dr. David Kupfer, of the University of Pittsburgh and chairman of the DSM-V task force.

The draft diagnostic criteria will then undergo two years of field testing. The final DSM-V is scheduled for release in May 2013, a year later than originally planned.

In the area of neurodevelopmental disorders, DSM-V will put dyslexia and dyscalculia -- reflecting disabilities of reading and mathematics, respectively -- into a new category of learning disabilities.

Autism, Asperger's syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified will make up the new "autism and related disorders" category.

The head of the APA's work group on substance-related disorders, Dr. Charles O'Brien, of the University of Pennsylvania, told reporters on the press call that substance dependence and abuse had no basis in the research on addictions.

"We unanimously agreed that… there really isn't evidence for an intermediate stage [short of addiction] that is now known as abuse," he said. Instead, there will be substance use disorders for each of the major types of drugs that cause problems, such as alcohol.

He added that the term "dependence" was problematic as a psychiatric diagnosis because some types of physical dependence are "completely normal" for some medications, such as opioid painkillers.

In fact, under the draft the DSM-V will include "discontinuation syndromes" to allow physicians to properly assess symptoms of withdrawal from psychoactive substances which include caffeine, O'Brien said.

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