Revising the book on mental illness

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After years of research, professional infighting and maneuvering from various interest groups, the nation’s psychiatrists Tuesday unveiled proposed changes to the manual used to diagnose and treat mental disorders around the world.

The draft document, released by the American Psychiatric Assn., for the first time calls for binge-eating and gambling to be considered disorders, opening the way for insurance coverage of these problems. But it refrains from suggesting a formal diagnosis for obesity, Internet addiction or sex addiction, as some professionals had proposed.

The document also recommends a single category for autism spectrum disorders, unifying what has been a multifaceted and complicated diagnostic scale.


The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders will be published in 2013. The book, which serves mental health professionals, is also used by insurance companies making decisions on treatment coverage and in courtrooms and schools. It was last revised in 1994.

The draft of the document will be displayed for public comment from Wednesday until April 20 at, allowing for input from individuals and organizations who may feel they’ve been left out of the revision process.

“This has been a massive effort on the part of a very dedicated team,” Dr. David Kupfer, chairman of the DSM-5 task force, said Tuesday at a Washington news conference. “Their priorities were to make sure the manual is based on scientific evidence, is useful to clinicians and maintains continuity with the previous edition wherever possible.”

DSM-5 is likely to list fewer diagnoses than the previous manual. Experts have proposed folding several disorders into single categories based on studies that suggest some disorders have similar origins, symptoms and treatments but only vary in severity.

For example, the four separate diagnoses related to autism -- autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified -- would now be referred to as autism spectrum disorders.

And the current categories of substance abuse and dependence will be referred to as “addiction and related disorders” -- a reflection that these problems cannot be easily categorized as mild or severe but occur on a continuum.


The loss of some categories is expected to be heavily criticized.

People with Asperger’s disorder, considered a mild form of autism characterized by difficulty with social relationships, see their condition as distinct, said Geraldine Dawson, chief science officer for Autism Speaks, a research and advocacy organization in New York.

“These different labels become part of a person’s identity. I think we need to be sensitive to that,” Dawson said.

Similarly, the proposal to place personality disorders in one category will not be welcomed by patient groups such as The Treatment and Research Advancements Assn. for Personality Disorders, which has championed specific research and treatment for one of these, borderline personality disorder.

“This will be a disaster,” said Valerie Porr, founder and president of the New York-based organization. “It kind of trivializes the personality disorders.”

Another possible point of contention is the suggestion of a category titled “risk syndromes” to describe what may be early signs of a mental disorder.

For example, 25% to 30% of people diagnosed with psychosis have early symptoms that include being suspicious of others and speaking nonsensically.


Some critics fear that categorizing people as “at risk” when they don’t yet have a full-blown disorder may lead to misdiagnosis and possible stigmatization.

But the category will not be used to screen the general public, only to diagnose people who are already in some distress and seeking help for their symptoms, said Dr. William T. Carpenter, Jr., chairman of the DSM-5 psychotic disorders work group.

For a person to even receive an “at risk” diagnosis, there must be some treatment known to help, he said.

Flagging and treating people early, Carpenter added, may stop a condition from developing into a serious impairment.

Other proposals, such as the addition of gambling disorder and binge-eating disorder, have been long endorsed.

“About 15 million people have binge-eating disorder,” said Lynn Grefe, chief executive of the National Eating Disorders Assn. “Hopefully, [this] would help them get the help that they need.”


One new category -- temper dysregulation with dysphoria -- is proposed to prevent misdiagnosis of children who have bursts of rage and can be moody, anxious and irritable. Such children are often diagnosed as having bipolar disorder and treated accordingly, sometimes with powerful medications.

The diagnosis of bipolar “is being given, we believe, too frequently,” said Dr. David Shaffer, a member of the work group on disorders in childhood and adolescence. In reality, when such children are tracked into adulthood, very few of them turn out to be bipolar, he said.

In some ways, the manual reflects a disappointing reality for psychiatrists. Despite many scientific advances, there are still no biological tests -- based on genes, blood markers or brain scans -- to help diagnose mental illness. Thus, diagnosis is based on description, a process that is, by its nature, subjective and vulnerable to criticism.

Work on DSM-5 began almost 10 years ago, and the draft reflects the work of 13 subcommittees in different areas of psychiatry. The project has generated criticism for its secrecy.

To limit influence of the pharmaceutical industry, DSM-5 committee members agreed to limit their income from industry sources to $10,000 per year while they work on the manual.