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

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.

APA announces draft diagnostic criteria for DSM-5

New proposed changes posted for leading manual of mental disorders

ARLINGTON, Va. ,11 feb 2010– The American Psychiatric Association today released the proposed draft diagnostic criteria for the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM). The draft criteria represent content changes under consideration for DSM, which is the standard classification of mental disorders used by mental health and other health professionals, and is used for diagnostic and research purposes.

"These draft criteria represent a decade of work by the APA in reviewing and revising DSM," said APA President Alan Schatzberg, M.D. "But it is important to note that DSM-5 is still very much a work in progress – and these proposed revisions are by no means final." The proposed diagnostic criteria will be available for public comment until April 20, and will be reviewed and refined over the next two years. During this time, the APA will conduct three phases of field trials to test some of the proposed diagnostic criteria in real-world clinical settings.

Proposed revisions

Members of 13 work groups, representing different categories of psychiatric diagnoses, have reviewed a wide body of scientific research in the field and consulted with a number of expert advisors to arrive at their proposed revisions to DSM. Among the draft revisions are the following:

• The recommendation of new categories for learning disorders and a single diagnostic category, "autism spectrum disorders" that will incorporate the current diagnoses of autistic disorder, Asperger's disorder, childhood disintegrative disorder and pervasive developmental disorder (not otherwise specified). Work group members have also recommended that the diagnostic term "mental retardation" be changed to "intellectual disability," bringing the DSM criteria into alignment with terminology used by other disciplines.
• Eliminating the current categories substance abuse and dependence, replacing them with the new category "addiction and related disorders." This will include substance use disorders, with each drug identified in its own category.
• Eliminating the category of dependence will better differentiate between the compulsive drug-seeking behavior of addiction and normal responses of tolerance and withdrawal that some patients experience when using prescribed medications that affect the central nervous system.
• Creating a new category of "behavioral addictions," in which gambling will be the sole disorder. Internet addiction was considered for this category, but work group members decided there was insufficient research data to do so, so they recommended it be included in the manual's appendix instead, with a goal of encouraging additional study.
• New suicide scales for adults and adolescents to help clinicians identify those individuals most at risk, with a goal of enhancing interventions across a broad range of mental disorders; the scales include research-based criteria such as impulsive behavior and heavy drinking in teens.
• Consideration of a new "risk syndromes" category, with information to help clinicians identify earlier stages of some serious mental disorders, such as neurocognitive disorder (dementia) and psychosis.
• A proposed new diagnostic category, temper dysregulation with dysphoria (TDD), within the Mood Disorders section of the manual. The new criteria are based on a decade of research on severe mood dysregulation, and may help clinicians better differentiate children with these symptoms from those with bipolar disorder or oppositional defiant disorder.
• New recognition of binge eating disorder and improved criteria for anorexia nervosa and bulimia nervosa, as well as recommended changes in the definitions of some eating disorders now described as beginning in infancy and childhood to emphasize that they may also develop in older individuals.

The APA has prepared detailed press releases on each of these topics, which are available on the DSM-5 Web site.

Dimensional Assessments

In addition to proposed changes to specific diagnostic criteria, the APA is proposing that "dimensional assessments" be added to diagnostic evaluations of mental disorders. These would permit clinicians to evaluate the severity of symptoms, as well as take into account "cross-cutting" symptoms that exist across a number of different diagnoses (such as insomnia or anxiety).

"We know that anxiety is often associated with depression, for example, but the current DSM doesn't have a good system for capturing symptoms that don't fit neatly into a single diagnosis, said David Kupfer, M.D., chair of the DSM-5 Task Force. "Dimensional assessments represent an important benefit for clinicians evaluating and treating patients with mental illness. It may help them better evaluate how a patient is improving with treatment, help them address symptoms that affect a patient's quality of life and better assess patients whose symptoms may not yet be severe – leading to earlier effective treatment."

Careful Consideration of Gender, Race and Ethnicity

The process for developing the proposed diagnostic criteria for DSM-5 has included careful consideration of how gender, race and ethnicity may affect the diagnosis of mental illness. The team has sought significant involvement of women, members of diverse racial and ethnic groups, and international researchers and clinicians. The APA also designated a specific study group to review and research these issues, and ensure they were taken into account in the development of diagnostic criteria.

The Gender and Cross-Cultural Study Group reviewed epidemiological data sets from the United States and other countries to determine if there were significant differences in incidence of mental illness among different subgroups (e.g., gender, race and ethnicity) that might indicate a bias in currently-used diagnostic criteria, including conducting meta-analyses (additional analyses combining data from different studies). Group members reviewed the literature from a broad range of international researchers who have explored issues of gender, ethnic and racial differences for specific diagnostic categories of mental illness. The study group also considered whether there was widespread cultural bias in criteria for specific diagnoses.

As a result of this process, the study group has tried to determine whether the diagnostic categories of mental illness in DSM need changes in order to be sensitive to the various ways in which gender, race and culture affect the expression of symptoms.

Public Review of Proposed Revisions

The resulting recommendations for revisions to the current DSM are being posted on the APA's Web site for the manual, www.DSM5.org, for public review and written comment. These comments will be reviewed and considered by the relevant DSM-5 Work Groups.

"The process for developing DSM-5 continues to be deliberative, thoughtful and inclusive," explained Dr. Kupfer. "It is our job to review and consider the significant advances that have been made in neuroscience and behavioral science over the past two decades. The APA is committed to developing a manual that is both based on the best science available and useful to clinicians and researchers."

Overview of DSM-5 Development Process

The last edition of DSM was published in 1994. Beginning in 2000, during the initial phase of revising DSM, the APA engaged almost 400 international research investigators in 13 NIH supported conferences. In order to invite comments from the wider research, clinical and consumer communities, the APA launched a DSM-5 Prelude Web site in 2004 to garner questions, comments, and research findings during the revision process.

Starting in 2007, the DSM-5 Task Force and Work Groups, made up of over 160 world-renowned clinicians and researchers, were tasked with building on the previous seven years of scientific reviews, conducting additional focused reviews, and garnering input from a wide range of advisors as the basis for proposing draft criteria. In addition to the work groups in diagnostic categories, there were study groups assigned to review gender, age and cross-cultural issues.

Based on the upcoming comments to the draft criteria and findings of the field trials, the work groups will propose final revisions to the diagnostic criteria in 2012. The final draft of DSM-5 will be submitted to the APA's Assembly and Board of Trustees for their review and approval. A release of the final, approved DSM-5 is expected in May 2013.

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The American Psychiatric Association is a national medical specialty society whose physician members specialize in the diagnosis, treatment, prevention and research of mental illnesses, including substance use disorders. Visit the APA at www.psych.org and www.healthyminds.org.