Psychiatrists weigh diagnostic manual revision

The American Psychiatric Association is proposing changes to the manual doctors use to diagnose and treat mental disorders including autism, addictions and schizophrenia.

The Diagnostic and Statistical Manual of Mental Disorders, which is also used by Canadian mental health workers, has not been updated since 1994. On Wednesday, the association proposed major changes to its diagnostic bible.

Doctors, insurers, scientists, and those in the legal system turn to the manual when drawing the line between what psychiatrists consider normal and not normal.

To propose the revisions, 13 expert groups convened conferences and consulted with more than 200 outside advisers including psychiatrists, neurologists and psychologists to review the latest scientific research in the field.

The draft changes include:

• Adding a new category called behavioural addictions, which so far includes only compulsive gambling. Internet addiction was considered for this category, but panelists decided there was not enough research data to include it.
• Recognizingbinge eating eating very large amounts of food at least once a week for three months and feeling severe guilt and unhappiness as a specific disorder distinct from bulimia, because binge eaters don't purge. Criteria for anorexia nervosa and bulimia nervosa would also beimproved, and the definitions of some eating disorders would change to reflect how they may develop after childhood.
• Broadening the diagnosis of autism spectrum disorders to include a range of conditions from mild social impairment to the more severerepetitive behaviours, instead of the current distinctions between autism, Asperger's syndromeand "pervasive developmental disorder."

"It's really important to recognize that diagnostic labels very much can be a part of one's identity," said Geri Dawson of the advocacy group Autism Speaks, which plans to take no stand on the autism revisions. "People will have an emotional reaction to this."

The APA group expects the changes could actually lower the numbers of people thought to suffer from mental disorders.

Avoiding overdiagnosis

"Is someone really a patient, or just meets some criteria like trouble sleeping?" APA president Dr. Alan Schatzberg, a psychiatry professor at Stanford University in California, told The Associated Press. "It's really important for us as a field to try not to overdiagnose."

The field of psychiatry has been criticized for adding diagnoses based on mild symptoms that had been considered normal, which could lead pharmaceutical companies to target new patients with heavy marketing to expand their markets and increase drug sales for antidepressants, stimulants and other medications.

Children as young as two have been diagnosed with bipolar disorder, and medical journal editorials have pointed to doctors receiving consulting and speaking fees from the makers of the drugs. Last year, pharmaceutical companies started publishing lists of such fees.

In a conference call with reporters on Tuesday, Dr. David Shaffer, a child psychiatrist at Columbia, said he and his colleagues on the panel working on the manual "wanted to come up with a diagnosis that captures the behavioural disturbance and mood upset, and hope the people contemplating a diagnosis of bipolar for these patients would think again."

A new feature of the draft manual, known as "dimensional assessments," would try to recognize that conditions such as insomnia and anxiety can overlap under different diagnoses. Doctors would also consider the severity of symptoms.

"We know that anxiety is often associated with depression, for example, but the current DSM doesn't have a good system for capturing symptoms that don't fit neatly into a single diagnosis," Dr. David Kupfer, chair of the DSM-5 Task Force, said in a release.

The new assessments may help doctors evaluate and treat how a patient is responding to treatment and address symptoms that affect a patient's quality of life, he added.

The revisions are being posted for public comment on the American Psychiatric Association's website at DSM5.org until April 20. If the revisions are adopted, they will be published in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, due in May 2013.