Psychiatry gets revised diagnostic manual

One of the biggest changes: 'autistic disorder' will now be known as 'autism spectrum disorder.'

04 dec 2012—The long-awaited revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) has been approved, bringing with it a series of revisions, additions and subtractions to the tome that is considered the Bible of psychiatry.

The revision, announced Saturday, has been more than a decade in the making and included input from more than 1,500 experts in all walks of medicine in 39 countries.

The changes to the DSM "will have some impact because there are some substantial changes in diagnostic criteria," said Dr. Bryan Bruno, acting chair of psychiatry at Lenox Hill Hospital in New York City. "The implications [will relate] not only to insurance coverage but to what we consider psychopathology. That is very much influenced by what the DSM says," he added.

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-4) has been in use since 1994. The new DSM-5 will be available in its entirety in the spring of 2013, according to the American Psychiatric Association (APA), which publishes the volume.

"We have produced a manual that best represents the current science and will be useful to clinicians and the patients they serve," APA president Dr. Dilip Jeste said in a statement from the association.

Although the new manual will include roughly the same number of disorders as the one it is replacing, a number of changes in content are significant.

One of the biggest revisions is a change in nomenclature for "autistic disorder," which will now be known as "autism spectrum disorder." That means Asperger's syndrome, a less debilitating form of autism, will be folded into the larger category and no longer have its own designation.

This change was met with some concern.

"Although there is a strong scientific rationale for these changes in the diagnostic criteria, we are concerned about the impact of the new DSM-5 criteria when they are used in real-world settings," said Geraldine Dawson, chief science officer of Autism Speaks, adding that the trials on the new criteria were based on a relatively small number of children.

"It is crucial that we monitor how the DSM-5 impacts diagnosis and access to services in the real world," she continued. "We want to make sure that no one is excluded from obtaining a diagnosis and accessing services who needs them."

Bruno said it was difficult to predict what sort of impact the inclusion of Asperger's within autism spectrum disorder would have on insurance coverage and access to services. Many clinicians already consider Asperger's part of the autism spectrum, he noted.

Another expert agreed.

Dr. Andrew Adesman, chief of developmental and behavioral pediatrics at the Steven and Alexandra Cohen Children's Medical Center of New York in New Hyde Park, said the new DSM is "codifying or formalizing what experts have been doing informally for years."

This is true not only for the term "autism spectrum disorder," which is already in wide use, but also for the age cutoff for symptoms of individuals with the inattentive form of attention-deficit/hyperactivity disorder (ADHD). The new DSM extends the age for symptom manifestation to 14, said Adesman.

Also in the new DSM-5, binge-eating disorder has been bumped up to a bona fide medical condition from one that simply needed "further study." With a formal code in hand, mental-health practitioners may now be able to get insurance reimbursement for treatment efforts.

Children may also now receive a diagnosis of "disruptive mood dysregulation disorder," a condition new to the DSM-5, which is characterized by "persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year."

Although the new diagnosis is intended to cut down on the number of children labeled with bipolar disorder, some say it simply medicalizes temper tantrums.

Bruno stressed, however, that the new disorder refers only to particularly severe tantrums that occur frequently. "This is much more extreme than a tantrum," he explained. "There are definitely those kids where the tantrums and irritability are very chronic and very severe. A lot of kids who were captured by a bipolar diagnosis may be captured by this."

Both excoriation (skin-picking) disorder and hoarding disorder are new to the DSM-5 and will appear in the chapter on "obsessive-compulsive and related disorders."

In another controversial change, certain people who are experiencing grief can now be diagnosed as having depression, an acknowledgment that "bereavement is a severe psychosocial stressor that can precipitate a major depressive episode," according to a news release issued by the APA.

Bruno believes that there will likely still be distinctions between "normal" grief and grief that is labeled depression.

In other changes, "gender identity disorder" is now "gender dysphoria," and dyslexia was not dropped from the manual, as some had feared might happen. Also, excessive "Internet gaming" now belongs to the category of conditions requiring "further research."

And there was one notable condition not added to the DSM-5: "hypersexual disorder," which many in the lay public refer to as sex addiction.

"The non-inclusion of sex addiction was not particularly surprising," Bruno said, because usually this behavior occurs as a symptom of other disorders, such as personality disorders, and is not something that psychiatrists commonly treat.

"We rarely see this as an entity in and of itself," Bruno said.

More information: The American Psychiatric Association has more on the DSM-5.