Just as primary and specialty care physicians change their diagnostic and treatment methods as research uncovers better ones, so to do mental health providers.
The Diagnostic and Statistical Manual of Mental Disorders, commonly referred to as DSM, is the gold standard for mental disorders used by mental health and other health professionals for diagnostic and research purposes. The current edition, the manual's fourth, was published in 1994, with some text revisions published six years afterwards. The American Psychiatric Association (APA) has, 10 year later, released the proposed diagnostic criteria for the upcoming fifth edition.
"These draft criteria represent a decade of work by the APA in reviewing and revising DSM," said Alan Schatzberg, M.D, president of the association. "But it is important to note that DSM-V is still very much a work in progress--and these proposed revisions are by no means final."
Which means DSM-V won't be hitting bookshelves just yet. The proposed changes are available for public comment until April 20, 2010. After that, the proposed criteria 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.
Some of the proposed revisions represent a fairly significant shift in thinking and understanding of some mental health disorders, and some have already stirred some controversy. Again, these revisions are just drafts and may be overhauled or rejected altogether before 2013.
Substance Abuse and Dependence
The proposed diagnostic criteria eliminate the current categories of substance abuse and dependence and replaces them with the new category "addiction and related disorders." This category would include "substance use disorders," with each drug identified as a category, such as "alcohol use disorder."
The Substance-Related Disorders Work Group members also have recommended a new category for behavioral addictions, in which gambling would be the sole disorder.
"The field of substance abuse and addiction has witnessed an explosion in important research in the past two decades," said David Kupfer, M.D., chair of the DSM-V Task Force. "These work group recommendations reflect the best science in the field and provide new clarity in how to diagnose these disorders."
The proposed criteria for substance use disorder are very similar to those now used to describe substance abuse and dependence in DSM-IV, although categories of "moderate" and "severe" would be added to describe severity. The symptom of drug craving would also be added, and the symptom of problems with law enforcement would be eliminated because of cultural considerations that make the criteria difficult to apply internationally.
"The term dependence is misleading because people confuse it with addiction, when in fact the tolerance and withdrawal patients experience are very normal responses to prescribed medications that affect the central nervous system," said Charles O'Brien, M.D., Ph.D., chair of the Substance-Related Disorders Work Group. "On the other hand, addiction is compulsive drug-seeking behavior, which is quite different. We hope that this new classification will help end this widespread misunderstanding."
Dr. O'Brien also explained the work group's reasoning behind the new category of behavioral addiction: "There is substantive research that supports the position that pathological gambling and substance use disorders are very similar in the way they affect the brain and neurological reward system," he said. "Both are related to poor impulse control and the brain's system of reward and aggression."
The proposed revisions also include a separate category that's not part of substance use disorder: "miscellaneous discontinuation syndromes." Withdrawal syndromes occur when a person has been taking a substance that's affected the central nervous system, and those cells have adapted over time to reduce their response to the substance. "If the substance is abruptly discontinued, in some cases the body responds with a rebound effect that creates unpleasant--and sometimes serious--symptoms of withdrawal," said Dr. O'Brien.
Assessment for Suicide Risk
The fifth edition's proposed diagnostic criteria include a new suicide assessment tool, developed to help clinicians better identify individuals at risk for suicide. A new "risk syndromes" category, which would include the two new diagnoses of psychosis risk syndrome and minor neurocognitive disorder, also has been proposed.
Two new scales have been proposed for assessing individuals' risk factors for committing suicide: one for adolescents and one for adults. While the current version of DSM includes thoughts of suicide as a symptom of some mental disorders, such as major depression, the proposed suicide risk techniques have been designed to be applied to anyone receiving an evaluation for a mental disorder, regardless of diagnosis, to help health care providers identify those patients at risk for suicide.
Said David Shaffer, M.D., a member of the Disorders in Childhood and Adolescence Work Group, "The use of a single research-based scale and accompanying record of assessment may help clinicians better assess suicide risk, as well as provide important information for researchers to help us more accurately identify and treat those at greatest risk for suicide."
The proposed scales are based on research identifying significant risk factors for suicide from follow-up studies and from "psychological autopsies" in which the past history of suicides and closely matched controls were compared.
The assessment tool for adolescents consists of a series of questions answered on paper or on a computer, methods found to be better than in-person questions for obtaining truthful answers about planned suicide in teens. The risk factors to be sought in adults include detailed planning of a potential suicide, chronic severe pain or illness, high or increased alcohol use, worsening of depression, increased anxiety and agitated behavior.
Mental Health Risk Syndromes
The APA is also considering including a new category in DSM-V for risk syndromes, in which identified symptoms place a person at higher risk of later developing a mental disorder. The first risk conditions proposed are psychosis risk syndrome and minor neurocognitive disorder, also known as mild cognitive impairment.
Psychosis risk syndrome presents as mild versions of the symptoms found in psychotic disorders, such as excessive suspicion, delusions and disorganized speech or behavior. Some 25 to 30 percent of people with these symptoms go on to develop a psychotic disorder. Because many of these symptoms, in their milder forms, can also be found in the general, healthy population, the Psychotic Disorders Work Group recommended the "risk syndrome" designation only be made for people whose symptoms are distressing or disabling enough to lead them to seek help.
"The concern in trying to identify people at the earliest stages of psychosis is that we may inaccurately diagnose some who are not at risk," explained William Carpenter, M.D., chair of the Psychotic Disorders Work Group. "But given the severity of psychotic disorders and evidence that early treatment may mitigate its long-term consequences, we believed that it was important to begin to recognize these conditions as early as possible."
The second proposed diagnosis, minor neurocognitive disorder, aims to identify people at greatest risk for eventually developing major neurocognitive disorder (dementia), which includes symptoms of severe loss of memory, language, attention, reasoning and level of independence. Major neurocognitive disorders include Alzheimer's dementia, vascular dementia and dementia from traumatic brain injury or HIV.
The proposed symptoms of minor neurocognitive disorder are similar but milder in severity: one to two standard deviations below the level of the healthy population, when adjusted for age and education. Additionally, the criteria require the person to experience a decline from his or her previous level of cognition so that people with life-long learning disabilities aren't misdiagnosed with minor neurocognitive disorder.
"The field of neurocognitive disorders is moving in the direction of earlier diagnosis, with an eventual goal of preventing further damage to the brain as new treatments become available," said Ronald Petersen, M.D., Ph.D., a member of the Neurocognitive Disorders Work Group. He added, "Even without currently available pharmaceutical treatments, early intervention may encourage patients to consider lifestyle changes such as physical exercise and intellectual activities that may reduce cognitive decline or encourage better planning for the future."
Another proposed diagnostic criterion for the fifth edition is a new recognition of binge eating disorder, along with minor changes in the criteria for anorexia nervosa and bulimia nervosa.
The best-known eating disorders are anorexia nervosa and bulimia nervosa. Anorexia nervosa primarily affects adolescent girls and young women; it's characterized by excessive dieting leading to severe weight loss accompanied by a pathological fear of becoming fat and distorted body image. Bulimia nervosa is characterized by frequent episodes of binge eating followed by inappropriate behaviors such as self-induced vomiting to avoid weight gain.
B. Timothy Walsh, M.D., chair of the Eating Disorders Work Group, explained that many individuals who seek treatment for an eating disorder don't meet the limited criteria in DSM-IV for these problems, thus their symptoms are classified in the large and heterogeneous category "eating disorder not otherwise specified." Therefore, the work group recommends several changes to the existing criteria for anorexia nervosa and bulimia nervosa, as well as the recognition of binge eating disorder.
Binge eating disorder is characterized by recurring episodes of consuming unusually large amounts of food that are accompanied by a sense of loss of control and strong feelings of embarrassment and guilt. The proposed criteria require such episodes to occur at least once a week over the preceding three months. Binge eating disorder is described in DSM-IV in an appendix, but since its publication, substantial new research has lead the Eating Disorders Work Group to believe it's time to make binge eating disorder a specific disorder within the revised manual.
"It is important that clinicians and the public be aware that there are substantial differences between an eating disorder such as binge eating disorder and the common phenomenon of overeating," said Dr. Walsh. "While overeating is a challenge for many Americans, recurrent binge eating is much less common and far more severe and is associated with significant physical and psychological problems."
"With the benefit of several decades of research and of information gleaned from clinical practice, we believe the ways to describe the problems of individuals with eating disorders can be significantly improved," said Dr. Walsh.
Autism Spectrum Disorders
Perhaps the proposed criteria revision that could attract the most controversy is the one to create a single diagnostic category, "autism spectrum disorders," to incorporate the current diagnoses of autistic disorder, Asperger's disorder, childhood disintegrative disorder and pervasive developmental disorder (not otherwise specified). The grouping of Asperger's disorder with autism has upset some advocates, who fear educators, health care providers, parents and others will mistakenly set the same lowered expectations for people with Asperger's as for people with autism, even though many people with Asperger's don't face the same difficulties and challenges as those faced by people with autism.
The recommended DSM-V draft criteria for autism spectrum disorders include a new assessment of symptom severity related to the individual's degree of impairment. The draft criteria also specify deficits in two categories:
- Social interaction and communication (for example, maintaining eye-to-eye gaze, ability to sustain a conversation and peer-relations)
- The presence of repetitive behaviors and fixated interests and behaviors
Additionally, in recognition of the neurodevelopmental nature of the disorder, the criteria require that symptoms begin in early childhood. Clinicians must take into account an individual's age, stage of development, intellectual abilities and language level in making a diagnosis.
"The recommendation of a new category of autism spectrum disorders reflects recognition by the work group that the symptoms of these disorders represent a continuum from mild to severe, rather than being distinct disorders," said Edwin Cook, M.D., a member of the Neurodevelopmental Disorders Work Group.
In addition to specifying a range of severity of autism spectrum disorders, the criteria include a description of the individual's overall development, course (for example, regression) and language. "We expect that the proposed changes will improve the sensitivity and specificity of the criteria for autism spectrum disorders, so that clinicians may be able to more accurately diagnose these disorders," noted Dr. Cook.
"In suggesting these revisions, the work group has considered the many advances in the field of autism and neurodevelopmental disorders, as well as the concerns of advocacy groups, family members and the medical groups who treat those living with autistic disorders," said Dr. Kupfer.
The work group has also recommended the diagnostic term mental retardation be changed to intellectual disability, bringing the manual's criteria into alignment with terminology used by other disciplines and the U.S. Department of Education. In addition, the work group recommends there be only one diagnosis for intellectual disabilities, with severity defined not only by IQ but also by impairments in adaptive functioning.
Yet another proposed revision is to include a new overarching category of "learning disabilities," containing two subcategories: dyslexia (learning difficulties related to reading) and dyscalculia (learning difficulties related to math). Dr. Cook emphasized that the diagnostic criteria were related to a person's age, intelligence and opportunity to acquire skills and that individually administered, culturally appropriate and valid measures should be used to evaluate the learning disabilities.
"It's important that we differentiate between the presence of a learning disability and the expected variations in individual abilities," Dr. Cook said.
A new diagnostic category, temper dysregulation with dysphoria (TDD), has been proposed for the fifth edition. This new category would appear in the "Mood Disorders" section of the manual.
Criteria for the proposed diagnosis of TDD include the following:
- Severe, recurrent outbursts of temper occurring three or more times a week that are grossly out of proportion to the situation or provocation and that interfere significantly with functioning
- Extreme verbal and physical displays of aggression when faced with a common minor demand or stress
- In between outbursts, the individual's mood is persistently negative: irritable, angry or sad
To be considered TDD, the symptoms must have begun before age 10. Only children over age 6 would be assigned the diagnosis, and children with the distinct manic episodes found in bipolar disorder would be excluded.
"Many children with these symptoms have received a diagnosis of one of the disruptive behavior disorders, such as oppositional defiant disorder, and in most cases that would be appropriate," said David Shaffer, M.D., chair of the ADHD and Disruptive Behavior Disorders Work Group. "However," Dr. Shaffer explained, "one of the most important longitudinal studies of adolescent symptoms and diagnoses has shown that many teens with these severe irritable and aggressive behaviors go on to develop depressive or anxiety disorders in adulthood, strongly linking these TDD symptoms to a mood disorder."
TDD offers a diagnosis that adequately describes the severity and frequency of this irritable behavior and highlights the significant--and often overlooked--mood disorder associated with it. By defining TDD, the work group hopes to also improve the accuracy of the diagnosis of bipolar disorder in children and teens.
"There has been a marked increase in the number of children diagnosed with bipolar disorder in the past decade," said Dr. Kupfer. "The new TDD criteria are based on research that helps us better differentiate children who have symptoms of bipolar disorder from those who do not."
Members of the Childhood and Adolescent Disorders Work Group developed the criteria for the proposed TDD diagnosis based on a decade of research examining the causes of chronic severe irritability. The original term used by researchers to describe these symptoms was severe mood dysregulation (SMD). The work group modified the criteria slightly and decided temper dysregulation with dysphoria was a more appropriate, descriptive name for the disorder.
Dr. Shaffer cautioned that TDD is very different from the irritation, anger and temper tantrums seen in normal development. "These are children whose outbursts may injure siblings, parents and schoolteachers," he said. "They may cause extensive damage to property, and the impact of their symptoms on family life is quite profound."
The work group members hope that specifying TDD as a specific diagnostic category will not only help clinicians more appropriately diagnose children with the disorder but also will encourage new research for appropriate treatments, including nonpharmaceutical interventions.
Based on the comments to the draft criteria and findings of the field trials taking place over the next two years, the work groups will propose final revisions to the diagnostic criteria in 2012. The final draft of DSM-V will be submitted to the APA's Assembly and Board of Trustees for their review and approval. A release of the final, approved fifth edition is expected in May 2013.