US psychiatry gets makeover in new manual

The latest makeover to a massive psychiatric tome honored by some, reviled by others and even called the "Bible" of mental disorders is being released Saturday with a host of new changes.

19 may 2013--The first major revamp in more than 20 years of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, will be unveiled in San Francisco at the annual meeting of the American Psychiatry Association.

Hoarding, gambling and marijuana withdrawal are among the newly expanded disorders contained in the fifth revision of the 947-page reference book.

Other categories have been redesigned, such as autism spectrum disorder, which is now the sole title for a range of previously separate diagnoses that used to include Asperger's, autistic and childhood disintegrative disorder.

The revision is based on new insights from research since the last version of the manual was published in 1990.

The book offers experts a common language for diagnosing mental disorders, and can play a role in what health insurance covers and does not.

The director of the National Institute of Mental Health, Thomas Insel, acknowledged that many of the changes were "contentious" but said "the final product involves mostly modest alterations of the previous edition."

However, the book and its changes have generated plenty of controversy, with critics saying it has the power to make certain common struggles into diagnosable disorders, possibly leading to overmedication of the population.

An early version of the DSM manual described homosexuality as a mental disorder, but that was eliminated in 1973.

In the new version, post-traumatic stress disorder will no longer be considered an anxiety disorder but will be classed under the chapter on trauma and stressor-related disorders.

In a bid to reduce incorrect diagnoses and prescriptions of anti-psychotic medication to children as young as two, the manual has created a new category for "disruptive mood dysregulation disorder," for hostility and outbursts beyond regular tantrums but not to the level of bipolar disorder.

Other changes include the removal of the grief-exclusion, which had said that people who have lost a loved one were not to be diagnosed with major depression, meaning the newly bereaved can now be diagnosed as depressed.

Gambling addiction is now included in the Substance Use Disorders chapter for the first time, and marijuana withdrawal will be considered a symptom of addictive disease.

Attention deficit hyperactivity disorder has been changed to include youths who show symptoms before age 12 instead of seven, and in adults five symptoms are required for diagnosis instead of six.

"Later age of onset and reduction in symptom counts in adults should lead to more accurate diagnosis," said Jeffrey Newcorn, director of the Division of Child and Adolescent Psychiatry at Mount Sinai Hospital.

"Although there will no doubt be concerns that the new criteria will lead to an increase in prevalence rates, the revised criteria should better align with clinical realities and support best treatment practices."

Obsessive-compulsive disorder has its own category for the first time, and includes the new hoarding disorder as well as body dysmorphic disorder and trichotillomania, or hair-pulling, which used to be considered impulse-control disorders.

Even though the DSM has generated plenty of discussion, the top US mental health official said its days as a guide for the psychiatry field may be nearing an end.

"While DSM has been described as a 'Bible' for the field, it is, at best, a dictionary, creating a set of labels and defining each," Insel wrote in a blog post in late April.

He said the focus of research should be on emerging research, not on the symptom clusters outlined in the DSM's categories.

"In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever," he wrote. "Symptoms alone rarely indicate the best course of treatment."

© 2013 AFP