A single diagnosis for autism and related disorders, a new label for many children now described as bipolar, and the classification of binge eating as a medical condition all figure in proposals unveiled today by the American Psychiatric Association (APA).
After more than two years of deliberation, the suggestions from 13 expert groups that have been working on the next edition of the Diagnostic and Statistical Manual of Mental Disorders are now . Interested parties have until 20 April to comment. The APA will then revise its proposals and launch a series of field trials to test the new diagnoses.
The new volume, known as DSM-V and scheduled for publication in 2013, has become a focus of controversy. Psychiatrists who led previous revisions of the manual are among those who have criticised its proposals. In particular, they have warned that some of the changes under consideration could cause millions more people to be given potentially risky psychoactive drugs.
Advertisement
Blurred boundaries
The APA鈥檚 leaders reject those criticisms, pointing out that one goal of the rewrite is to streamline psychiatric diagnosis. For instance, they propose removing various subtypes of schizophrenia, and collapsing a variety of personality disorders into one condition. 鈥淲e are likely to end up with fewer disorders in DSM-V than in DSM-IV,鈥� says , the association鈥檚 president.
This does not reassure those who are concerned that the new criteria may blur the boundaries between normal behaviour and mental illness. The most controversial suggestion is for new 鈥渞isk syndromes鈥� for types of psychosis and dementia.
The possible adoption of risk syndromes for psychosis has caused particular alarm, given the side effects of antipsychotic drugs 鈥� which include weight gain and loss of libido 鈥� and the fact that only around 30 per cent of people identified as being at risk will go on to develop psychosis within two years.
鈥淭hey don鈥檛 seem to be that concerned about excluding false positives,鈥� complains Robert Spitzer, a retired psychiatrist who chaired the DSM-III revision.
William Carpenter of the University of Maryland in Baltimore, who chairs the DSM-V work group on psychosis, says that over the next two years his group will review the available research to consider whether psychosis risk should be included in DSM-V, or instead be listed in an appendix, to encourage more studies.
Prolonged grief
The dementia risk category, called 鈥渕inor neurocognitive disorder鈥�, is intended to identify people whose mental decline might be slowed if they are encouraged to engage in intellectual activities and physical exercise.
Michael First, a psychiatrist at Columbia University in New York, is concerned that it will instead serve as a flag to health insurers, who may end up denying coverage to people identified in this way, to avoid having to bear the cost of expensive treatment years later. 鈥淚nsurance companies want to reduce their risk of having to pay out,鈥� he says.
With the proposals now published online, critics have a chance to weigh in before the start of field trials, planned for July. 鈥淭he good news is that there is something to look at,鈥� says Spitzer. 鈥淭he bad news is that there鈥檚 not an enormous amount of time to make changes.鈥�
Some potential revisions are still missing, as the necessary work was not completed in time. These include a possible new diagnosis of 鈥減rolonged grief鈥�, to recognise the plight of those who remain stricken by the death of a loved one.
Significant proposals
Below we outline other significant areas where proposals are now open for public comment:
Binge eating disorder
Do you consume unusually large amounts of food at least once a week, and feel a loss of control, embarrassment and guilt? Has it been this way for at least three months? If so, you meet the criteria for the proposed new condition of 鈥渂inge eating disorder鈥�. The impetus for its inclusion comes in part from a 2007 study which suggests that it is as common in the US as anorexia and bulimia combined.
But its high frequency is exactly what concerns psychiatrist Michael First, who wonders if normal behaviour is being turned into a psychiatric disease. 鈥淥nce a week for three months seems like a low threshold,鈥� he says. 鈥淗ow abnormal is that?鈥�
Possible treatments for binge eating include not only cognitive-behavioural therapy, but also antidepressants and appetite suppressants, so drug companies have an interest in whether binge eating gets included in DSM-V.
Autism spectrum disorders
The work group dealing with neurodevelopmental disorders wants to cut through the confusion surrounding autism and related conditions. In their place it wants to create a single diagnosis to cover the entire spectrum.
At present, children who display problems with social interaction and communication are given a variety of diagnoses, including autistic disorder and Asperger鈥檚 syndrome. The latter is usually reserved for those with stronger language skills.
While some patients prefer the label of Asperger鈥檚, perceiving it to carry less stigma, the backs the working group鈥檚 proposal. 鈥淭he right thing is to look at this as a spectrum,鈥� argues ASAN鈥檚 vice-president Scott Robertson, who himself has an Asperger鈥檚 diagnosis.
At present, different doctors approach patients on this spectrum in different ways. 鈥淎n individual can see three different clinicians and get three different diagnoses,鈥� says Robertson. This diagnostic uncertainty can be a problem in some US states, where provisions such as helpers for children at school may only be given to those with the core diagnosis of autistic disorder.
Paraphilic coercive disorder
The notion that some men are especially turned on by rape, a condition dubbed 鈥減araphilic coercive disorder鈥�, and a shift in the definition of paedophilia to include a 鈥渉ebephilic鈥� type, referring to men who are fixated on pubescent girls, would enter the DSM-V under controversial proposals from its sexual disorders work group.
The validity of both conditions is hotly debated, but the inclusion of either of them in DSM-V would have important legal ramifications. If they are recognised as psychiatric disorders, a diagnosis could be used to keep sex offenders who have served their jail time locked away indefinitely under 鈥渃ivil commitment鈥� statutes passed by 20 US states.
Temper dysregulation with dysphoria
This proposed classification would apply to some children currently diagnosed with childhood bipolar disorder, which is perhaps the most controversial psychiatric condition in the US today. Rates of diagnosis rose more than fivefold between 1994 and 2006, and concern has grown about the widespread use of mood stabilisers and antipsychotics to treat these children.
According to , a child psychiatrist at Stony Brook University in New York, diagnosis of juvenile bipolar disorder has expanded as a knock-on from previous diagnostic shifts, including a narrowing of conduct disorder to focus on children who will go on to become adults with antisocial personality disorder. At the same time, attention-deficit hyperactivity disorder (ADHD) has been 鈥済entrified鈥� to include children with milder problems, which makes it less helpful for dealing with more seriously disturbed children.
This has left psychiatrists looking for a label for children who swing between severe outbursts of aggression and periods of irritability, anger and sadness, and bipolar disorder has become a popular choice. 鈥淭he diagnosis of juvenile bipolar disorder is being given, we believe, too frequently,鈥� says of Columbia University in New York, who chairs the DSM-V work group on ADHD and disruptive behaviour disorders.
鈥淭emper dysregulation with dysphoria鈥� is the work group鈥檚 proposed solution. Children with this diagnosis are still likely to be given drugs, probably a stimulant such as Ritalin, plus an antipsychotic 鈥� possibly as a temporary measure, rather than as a long-term prescription.
