Mental Illness Manual Rewritten

Feb. 10, 2010 - The first draft of the new psychiatric manual -- the DSM-V, to be finalized in 2013 -- makes major changes in how a wide range of mental illnesses will be diagnosed.

Nothing is set in stone, says the American Psychiatric Association (APA) task force that is writing the new diagnostic "bible" -- the Diagnostic and Statistical Manual of Mental Disorders Version V, which will replace the DSM-IV written in 1994.

But some of the changes would be radical:

• Say good-bye to Asperger's syndrome -- it would now be at the mild end of the "autism spectrum disorder."
• Say hello to "temper dysregulation with dysphoria" or TDD, a new category of mood disorder for some children now lumped together with those suffering the more severe bipolar disorder.
• Say good-bye to "substance abuse" and "substance dependence." Addiction disorders would be named after the addictive substance, such as "cannabis-use disorder" and "alcohol-use disorder."
• A new category of "risk syndromes" would diagnose troubled teens with symptoms such as disordered thinking as having "psychosis risk syndrome."

Public comments are welcome until April 20, and the new diagnoses will be tested in three sets of field trials before the DSM-V becomes final.

The process has been anything but smooth. Two of the leaders of the task force that wrote the current manual have strongly criticized the way the new task force is doing its job. Back-and-forth commentaries between them and the leaders of the new task force and the APA leadership, published in the Psychiatric Times, have degenerated into personal attacks.

One expert with a foot in both worlds -- he is the editor of several DSM-IV publications and directed the DSM-V prelude project -- is Michael B. First, MD, professor of psychiatry at Columbia University and a researcher at New York State Psychiatric Institute.

"This is what always happens when something is new," First tells WebMD. "But overall, this is definitely not a paradigm shift. ... If this were the final draft, it would be time to call out the fire department. But now that these things are on the table, I'm hopeful that ideas that are possibly not the best will be taken away."

First likes a lot of what he sees in the new DSM-V. For example, he likes the new manual's emphasis on suicide prevention, and its effort not just to diagnose a disorder but to give a clearer idea of its severity.

On the other hand, First is disturbed by the proposed diagnosis of people as having risk syndromes for psychosis and dementia.

"Psychotic risk syndrome is the worst idea in the whole thing," First says. "Only 10% to 20% of people who meet the criteria for risk will actually become psychotic. That means that eight in 10 will get no benefit -- and what is the benefit? There is no way to prevent schizophrenia. And then there is the stigma. ... And the potential for normal people being captured under this rubric is high."