Big Changes in Psychiatry's 'Bible' of Disorders

Dec. 3, 2012 -- A major revision to the diagnostic "bible" -- which defines what is and what is not a mental illness -- has the final approval of the American Psychiatric Association (APA).

The approval means the final draft of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, will be official when it is published in May 2013.

Ten years in the making, the rewritten manual has been embroiled in controversy. One outspoken critic is Allen J. Frances, MD, chair of the task force that developed the previous edition, DSM-IV.

In a critique published online by Psychology Today, Frances calls the DSM-5 "deeply flawed," with "changes that seem clearly unsafe and scientifically unsound."

The APA defends the DSM-5 as the work of more than 1,500 experts in all fields of psychiatry and psychology from 39 countries.

"We have produced a manual that best represents the current science and will be useful to clinicians and the patients they serve," Dilip Jeste, MD, president of the APA, says in a news release.

Something called "psychotic risk syndrome," one of the most controversial proposed diagnoses, was dropped from the final draft. "Hypersexual disorder" (sex addiction) was also rejected, although the new manual opens the door to "behavioral addictions."

Major Changes in DSM-5

The APA points to several key decisions for the DSM-5, including:

• Asperger's disorder, childhood disintegrative disorder, and pervasive developmental disorder will no longer be specific diagnoses. Instead, children with these conditions will receive diagnoses of autism spectrum disorder with different degrees of severity.
• Binge-eating disorder is now an official diagnosis. "Excessive eating 13 times in three months is no longer just a manifestation of gluttony and the easy availability of really great tasting food," Frances says. But the APA says the change "better represents the symptoms and behaviors of people with this condition."
• Children with persistent irritability and frequent tantrums (three or more a week for over a year) will receive a diagnosis of disruptive mood dysregulation disorder. The APA says this addresses concerns about the over-diagnosis of ADHD. Frances says it will do the opposite, by turning temper tantrums into mental disorders.
• Skin picking will be a new disorder related to obsessive-compulsive disorders.
• Hoarding is a new disorder that will describe "people with persistent difficulty discarding or parting with possessions, regardless of their actual value."
• Grief used to be considered normal in people with symptoms of depression lasting less than two months after the death of a loved one. Now such people may receive a diagnosis of depressive disorder. "This reflects the recognition that bereavement is a severe psychosocial stressor that can precipitate a major depressive episode beginning soon after the loss of a loved one," the APA says. Frances says the change will substitute "pills and superficial medical rituals for the deep consolations of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life."
• Substance-use disorder now combines the old categories of substance abuse and substance dependence. The APA says this strengthens the diagnosis. Frances says "first-time substance abusers will be lumped in ... with hard-core addicts."