Big Changes for the Psychiatrist's 'Bible'

He also said his work group had considered including sex and Internet addictions as disorders, but decided there was insufficient evidence to develop reliable diagnostic criteria for them. Consequently, gambling addiction is slated to be the only disorder formally listed in the behavioral addictions category.

But O'Brien added that under current plans, sex and Internet addiction would be included in an appendix to DSM-V, intended to encourage additional research that could lead to their inclusion in future editions.

APA leaders also emphasized the two new suicide risk assessment scales planned for DSM-V, one for adolescents and one for adults.

Dr. David Shaffer, of Columbia University, told reporters on the press call that suicide nearly always occurs in the context of some psychiatric disorder, but not always depression.

The new risk assessment tools focus on risk factors such as impulsive behavior, heavy drinking, and chronic severe pain and illness.

In DSM-IV, suicidal ideation is treated as a symptom of major depression and certain other disorders.

Shaffer also explained the genesis of the proposed new childhood disorder, temper dysregulation with dysphoria (TDD).

"About 40 percent to 60 percent of the cases [seen by child psychiatrists] will be children who are doing things that other people don't want them to do," he said. Many of these are children who are "stubborn and resistant and disobedient and moody."

There is currently a recognized syndrome known as oppositional defiant disorder, but some children also display severe aggression and negative moods that go beyond mere stubbornness, according to Shaffer.

Such children are often tagged as having juvenile bipolar disorder, but research has shown that the label is often inappropriate, since they usually do not qualify for a bipolar disorder diagnosis when they reach adulthood, though they remain dysfunctional. More often, these children are diagnosed as depressed when they become adults.

He said the addition of TDD would better describe the severity and frequency of irritable behavior while also recognizing the mood disorder that goes with it.

Another innovation in DSM-V will be the extensive use of so-called dimensional assessments. Whereas DSM-IV relied heavily on present-absent symptom checklists, the new edition will include severity scales for symptoms such as anxiety or insomnia that may appear to larger or smaller degrees in many different mental illnesses.

Dr. Darrel Regier, the APA's research director, said such checklists "don't always fit the reality that someone with a mental disorder experiences." Often, a symptom like insomnia isn't on the checklist for a particular disorder, he said, "but they can still affect patients' lives and affect the treatment planning."

Incorporating quantitative dimensional assessments should allow clinicians to develop treatment and response-monitoring plans better tailored to individual patients' needs, Regier said.

A closely watched issue in the DSM-V revision has been whether to change or do away with gender identity disorder, now listed in DSM-IV. At this point, the draft retains the designation but with some changes, officials said.

People who consider themselves "transgendered" have long criticized DSM-IV and previous editions for labeling them with a mental disease when their problems, they believe, are purely somatic -- that is, they have the wrong genitalia and hormonal balance.

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