On Saturday, the American Psychiatric Association (APA) finalized a 13-year process of revising the Diagnostic and Statistical Manual of Mental Disorders, commonly known as the DSM, the most important book in the field of mental illness. The DSM attempts to designate and code all the ways our minds can go awry. It defines depression, anxiety, schizophrenia — as well as more than 300 other problems from obsessive-compulsive disorder to stuttering to fetishism. Insurance companies require DSM codes for reimbursement, and the National Institutes of Health require them for research grants. It’s no exaggeration to say that the new DSM — the fifth full edition, one that more than 1,500 mental-health experts help write — will change the world of mental health.
Here are some of the biggest changes:
1. Autistic disorder will become autism-spectrum disorder. That spectrum will incorporate Asperger’s syndrome, which generally involves milder forms of autism’s social impairments and previously had its own code number (299.80). To guide clinicians, the DSM will include specific examples of patients meeting criteria for the different disorders making up the spectrum, from autistic disorder to Asperger’s, childhood-disintegrative disorder and pervasive developmental disorder (not otherwise specified). Combining autism and Asperger’s is especially controversial partly because autism can be so much more serious than Asperger’s. Although some autistic people function extremely well (the livestock expert Temple Grandin has helped change her field), others affected by the disorder need lifelong care for basic needs. The change will likely cause considerable debate, however, since the diagnosis is a requirement for access to some of the educational and social services that make up this care, and it’s not clear yet how the change in definition will affect such eligibility in the future.
2. Binge-eating disorder will be moved from DSM‘s Appendix B — a category of proposed conditions that require “further study” — to a full-blown illness in the main part of the book. The shift will create a significant new market for mental-health professionals who will now be able to apply for insurance reimbursement for patients who binge eat. A major criticism of considering binge eating a distinct disorder is the difficulty in distinguishing whether consuming an entire pint of Ben & Jerry’s could be a sign of depression or anxiety rather than an illness of its own. But in recognizing recent research that suggests that there are unique features to binge eating involving distorted-body-image issues, the APA in its press release on the DSM changes says that “the [binge-eating-disorder] change is intended to better represent the symptoms and behaviors of people with this condition.”
3. The new DSM will remove the exception for bereavement from the definition of depression, which means psychiatrists will be able to diagnose depressive disorder even among those who have just lost a loved one. For years, skeptics have criticized the APA for its expansive meaning of depression; now that definition is even broader.
4. Continuing the expansion of diagnostic criteria, the new DSM will also include a controversial new diagnosis called “disruptive mood dysregulation disorder (DMDD),” a label that can be attached to “children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year.” Earlier this year, the Huffington Post called DMDD the “tantrum diagnosis,” and a blogger for Wired warned that the new disorder “could be anything, like the meltdown when the shoes can’t be found, the homework got lost, or the braids aren’t quite right.” But the APA says the new diagnosis “is intended to address concerns about potential over-diagnosis and over-treatment of bipolar disorder in children.”
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5. DSM-5 will also incorporate the extremely rare disorders of excoriation (skin picking) and hoarding. The current DSM does list trichotillomania (obsessive hair pulling), but adding reality-show problems such as skin picking and hoarding has bolstered criticisms of diagnosis creep. Hoarding was previously considered a form of obsessive-compulsive disorder.
What will not be added to the DSM is hypersexual disorder — sex addiction — even though many APA members argued for its inclusion. According to one member of the APA’s board of trustees: “The evidence just wasn’t there.” Other mental-health professionals note that the DSM is subject to political influence. “This is a huge moneymaker for the American Psychiatric Association,” says Marsha Linehan, a University of Washington professor and a leading expert on personality disorders. The decisions reflect the votes of the APA’s board of trustees; the entire membership will vote on the revisions later in the spring, but experts don’t expect additional alterations. Which means that the approval this weekend of DSM-5 ends years of editing but begins years of debate.
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