[News/Health] [USA] DSM-V Draft Promises Big Changes in Some Psychiatric Diagnoses
Stephanie Stevens
---
Excerpt: 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. [...] William Narrow, MD, 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.
---
DSM-V Draft Promises Big Changes in Some Psychiatric Diagnoses
By John Gever, Senior Editor, MedPage Today
Published: February 10, 2010
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) has posted the draft of
DSM-V on a special Web site, www.dsm5.org, to obtain comments from its
members, other members of the mental health community, and the public.
At a telephone press briefing before the draft's release, members of
the APA team leading the DSM revision highlighted several substantial
innovations they are proposing:
* Recategorizing 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, 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 David Kupfer, MD, of the University of
Pittsburgh, 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
<http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/17482> .
New Categories for Dyslexia, Autism
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,
Charles O'Brien, MD, PhD, 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, DSM-V will include "discontinuation
syndromes" to allow physicians to properly assess symptoms of
withdrawal from psychoactive substances, including 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 allow development of 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
addictions would be included in an appendix to DSM-V, intended to
encourage additional research that could lead to their inclusion in
future editions.
Carole Lieberman, MD, a Beverly Hills, Calif., psychiatrist who
appears frequently on television, regretted the omission of Internet
addiction.
Contacted for comment by MedPage Today and ABC News, Lieberman said in
an e-mail that behavioral addictions are a worthy category. "But why
would it not include 'Internet addiction,'" she wrote. "Could it be
that the psychiatrists involved do not want to acknowledge that their
own Internet usage could meet the criteria for addiction?"
Lieberman added that compulsive shopping was another form of
behavioral addiction that deserves recognition.
Dimensional and Risk Assessments
APA leaders also emphasized the two new suicide risk assessment scales
planned for DSM-V, one for adolescents and one for adults.
David Shaffer, MD, 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% to 60% 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, although 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.
Darrel Regier, MD, MPH, 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.
But Lieberman foresaw problems with the dimensional assessments. "I
don't think [they] will add anything but confusion," she said in an
e-mail. "As it is now, people don't really make use of the
subcategories that there are to describe severity of symptoms.
Instead, I see this as a tool that insurance companies could well
co-opt to try to deny benefits."
Gender Identity Disorder Stays
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
<http://www.medpagetoday.com/MeetingCoverage/APA/14270> 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 payment for gender transition treatments, they
said.
William Narrow, MD, 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.
This article was developed in collaboration with ABC News.
© 2004-2010 MedPage Today, LLC. All Rights Reserved.
http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/18399