New Diagnostic Guidelines for Mental Illnesses Proposed
WEDNESDAY Feb. 10, 2010 -- For the first time in more than a decade, the American Psychiatric Association has announced proposed changes to the Diagnostic and Statistical Manual of Mental Disorders (DSM), long considered the "Bible" of psychiatry.
Unlike its predecessor, DSM-4, the new DSM-5 would not formally recognize sex and Internet addictions; would create a new category for "risk" disorders for people possibly heading towards developing full psychosis or dementia; and would create a new disorder, "temper dysregulation with dysphoria" (TDD) to incorporate both mood and behavioral disturbances, partly a response to current overdiagnosis of juvenile bipolar disorder.
Other issues were also addressed, including creating an overarching category known as "autism spectrum disorders" to encompass autism, Asperger's syndrome and other similar conditions. This term is already widely used. And "mental retardation" would become "intellectually challenged."
DSM is the tome used by psychiatrists and other mental health professionals to diagnose different conditions and to guide research.
The proposed draft will be available for public comment until April 20. The final document, which has already been 10 years in the making, is expected to be released in 2013. The DSM-4 was published in 1994.
One of the major changes in the proposed volume will be a move toward "dimensional assessments" for mental disorders, meaning that strict, immutable categories will be replaced by a reliance on continuums and that "cross-cutting" symptoms -- those that span several different disorders -- will be included in the criteria.
"There's no measure in the [DSM-4] to account for the severity of the disorder and therefore no way to measure if a patient, on quantitative measures, is improving with treatment," Dr. Darrel Regier, vice chair of the DSM-5 Task Force and director of research for the American Psychiatric Association, said during a Tuesday teleconference announcing the proposed changes. "We're trying to address this with more quantitative measures on a continuum with a cut-off to decide mild, severe, very severe."
This time around, experts say they are giving "careful consideration" to how mental health disorders might vary according to race, gender and ethnicity.
Some of the other proposed changes:
- A diagnosis of autism spectrum disorders would compress into a single category several disorders that used to be considered separately. Also, one diagnosis for intellectual disability would replace separate categories of profound retardation and a new, overarching category of learning disabilities that merge dyslexia (related to reading) and dyscalculia (related to mathematics).
- The diagnoses "substance abuse" and "substance dependence" will now become "addiction and related disorders," including "substance use disorders" such as "alcohol use disorder" and "cocaine use disorder." A new category, "miscellaneous discontinuation syndrome" covers instances of "normal" responses of withdrawal from a drug. "This also fits the category of caffeine," said Dr. Charles P. O'Brien, chair of the Substance-Related Disorders Work Group and a professor of psychiatry at the University of Pennsylvania School of Medicine.
- A new category of "behavioral addictions" has been created which, at this point, includes only gambling. Internet and sex addiction so far merit only inclusion in the appendix. "We couldn't find enough scientific evidence for the existence of sex addiction, but we did feel that gambling merited inclusion and we seriously considered Internet addiction," O'Brien said. Both sex and Internet addictions are included in the appendix "to stimulate research," he explained.
- The DSM-5, as proposed, would also include a "risk syndrome," to identify people at risk for certain disorders such as psychosis and dementia, which now becomes minor neurocognitive impairment and major neurocognitive impairment. This controversial feature (critics have said this practice unfairly labels and stigmatizes people) would allow for early intervention in people fitting the criteria.
- Experts recommended using two different scales to assess suicide risk, one for adults and one for adolescents, intended to better identify at-risk individuals.
- The new disorder, "temper dysregulation with dysphoria," would be added to the mood disorders section. TDD would include both behavioral and mood problems and, hopefully, will avoid overdiagnosis of juvenile bipolar disorder. "The diagnosis of juvenile bipolar disorder is being given rather too frequently," said Dr. David Shaffer, a member of the Disorders in Childhood and Adolescence Work Group and a professor of child psychiatry and of pediatrics at Columbia University. "The new diagnosis captures both the behavioral disturbance and the mood upset. We hope people contemplating a diagnosis of bipolar disorder will think again."
- Binge eating would become the newest eating disorder. "We're quite confident that, compared to other folks, these people are more distressed, have more symptoms of anxiety and mood disturbance, indications that their treatment may be better provided if it's done in a somewhat different way than with other folks with similar weight problems," said Dr. B. Timothy Walsh, chair of the Eating Disorders Work Group and a professor of pediatric psychopharmacology at New York State Psychiatric Institute. The DSM-5 would also include better criteria for diagnosing anorexia nervosa and bulimia nervosa.
The DSM-4 was widely criticized for "overpathologizing" ordinary and expected human experiences and emotions.
"Every time the DSM is revised it gets bigger and there seem to be more and more disorders, and new ones seem to be invented," said James Maddux, a professor of psychology at George Mason University in Fairfax, Va. "There has been a gradual psychopathologizing of everyday problems in living."
The DSM-5, however, might escape such criticisms, Maddux conceded.
"Any movement towards a dimensional model is a move in the direction of being consistent with the research," he said. "Any change that reduces the probability that someone with a normal, expected problem in living is going to be said to have a mental disorder is also a move in the right direction."
View and comment on the proposed changes by visiting the American Psychiatric Association.
Posted: February 2010