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.

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.

At the APA's annual meeting last May, members of the transgender community made a case for dropping gender identity disorder from DSM-V, but keeping some kind of "gender variance" diagnosis as a medical condition. Such an approach would eliminate the stigma of a psychiatric diagnosis while leaving a pathway for third-party (insurance) payment for gender transition treatments, they said.

Dr. William Narrow, the APA's research director for DSM-V, told reporters that the draft does remove the term "disorder" from the condition when applied to children, renaming it as "gender incongruence."

For adults, gender identity disorder will remain in DSM-V but with substantially altered diagnostic criteria, Narrow said.

But APA officials said the organization planned more discussions with members of the transgender community.

Kupfer, the DSM-V task force chairman, stressed that further changes in many diagnostic categories are likely following the comment period and field trials. Final revisions will be submitted in 2012 for approval by the APA's two governing bodies, the Assembly and the board of trustees.

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