Feb 14, 2010

Overview of Proposed DSM-V Changes


There are no proposed changes to the diagnosis of Reactive Attachment Disorder. In addition, the proposals to add Developmental Trauma Disorder of Complex Trauma have been rejected, which is most unfortunate. Many children who have experienced chronic early maltreatment within a caregiving relationship exhibit a range of symptoms across several domains. Without a diagnostic category of Developmental Trauma Disorder that captures the range and depth of dysfunction, we are left giving children a basket of different diagnoses. This can lead to treating a range of symptoms and not the underlying causative factors.

There are substantial changes proposed for the Diagnostic and Statistical Manual of Mental Disorders.
The American Psychiatric Association (APA) has posted the draft of DSM-V on a special Web site, www.dsm5.org, to obtain comments.
A few of the proposed major changes:
• 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 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.
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 a 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. The draft, DSM-V will include "discontinuation syndromes" to allow for the proper assessment of symptoms of withdrawal from psychoactive substances, including caffeine.
Dimensional and Risk Assessments
There are two new suicide risk assessment scales planned for DSM-V, one for adolescents and one for adults. 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.
Temper Dysregulation Disorder to be used in some cases instead of Bipolar Disorder
There is a proposed new diagnosis. The proposed new childhood disorder, temper dysregulation with dysphoria (TDD). It is reported that about 40% to 60% of the cases seen will be children who are doing things that other people don't want them to do. Many of these are children who are "stubborn and resistant and disobedient and moody, according to David Shaffer, MD, of Columbia University. 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.
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, according to Dr. Shaffer. 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.
Dimensional Assessment
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.
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. In the draft, APA leaders are proposing to rename the condition "gender incongruence" for adults and children.
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 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.
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.

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