ASAN Vice President on talks about new DSM-V Autism Criteria in New Scientist

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Psychiatry's draft new 'bible' goes online

- 15:49 10 February 2010 by *

Aldhous*<http://www.newscientist.com/search?rbauthors=+Aldhous>

- For similar stories, visit the *Mental

Health*<http://www.newscientist.com/topic/mental-health> Topic

Guide

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 nowavailable

online<http://www.dsm5.org/Pages/Default.aspx>.

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<http://www.newscientist.com/article/mg20427381.300-psychiatrys-civil\

-war.html>.

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.

Blurred boundaries

The APA's 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. " We are likely to end up with

fewer disorders in *DSM-V* than in *DSM-IV*, " says Alan

Schatzberg<http://med.stanford.edu/profiles/neuroscience/faculty/alan_schatzberg\

/>,

the association's 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 " risk syndromes " 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 – which include weight

gain and loss of libido – 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.

" They don't seem to be that concerned about excluding false positives, "

complains Spitzer, a retired psychiatrist who chaired the *DSM-III*

revision.

Carpenter of the University of land 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 " minor neurocognitive disorder " , is

intended to identify people whose mental decline might be slowed if they are

encouraged to engage in intellectual activities and physical exercise.

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. " Insurance companies want

to reduce their risk of having to pay out, " he says.

With the proposals now published online, critics have a chance to weigh in

before the start of field trials, planned for July. " The good news is that

there is something to look at, " says Spitzer. " The bad news is that there's

not an enormous amount of time to make changes. "

Some potential revisions are still missing, as the necessary work was not

completed in time. These include a possible new diagnosis of " prolonged

grief " , 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 " binge eating disorder " . 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<http://www.newscientist.com/article/dn11091-bingeing-cited-as-biggest-e\

ating-disorder-in-us.html>

..

But its high frequency is exactly what concerns psychiatrist First,

who wonders if normal behaviour is being turned into a psychiatric disease.

" Once a week for three months seems like a low threshold, " he says. " How

abnormal is that? "

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's syndrome. The latter is usually reserved for those with

stronger language skills.

While some patients prefer the label of Asperger's, perceiving it to carry

less stigma, the Autistic Self Advocacy

Network<http://www.autisticadvocacy.org/> backs

the working group's proposal. " The right thing is to look at this as a

spectrum, " argues ASAN's vice-president on, who himself has an

Asperger's diagnosis.

At present, different doctors approach patients on this spectrum in

different ways. " An individual can see three different clinicians and get

three different diagnoses, " says on. 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 " paraphilic coercive disorder " , and a shift in the definition of

paedophilia to include a " hebephilic " 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

" civil commitment " 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<http://www.newscientist.com/article/mg19426043.900-bipolar-children--is-the\

-us-overdiagnosing.html>,

and concern has grown about the widespread use of mood stabilisers and

antipsychotics to treat these children.

According to le

Carlson<http://www.hsc.stonybrook.edu/som/psychiatry/carlson_g.cfm>,

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 " gentrified " 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. " The

diagnosis of juvenile bipolar disorder is being given, we believe, too

frequently, " says

Shaffer<http://asp.cumc.columbia.edu/facdb/profile_list.asp?uni=ds18 & DepAffil=Ps\

ychiatry>

of

Columbia University in New York, who chairs the *DSM-V* work group on ADHD

and disruptive behaviour disorders.

" Temper dysregulation with dysphoria " is the work group's proposed solution.

Children with this diagnosis are still likely to be given drugs, probably a

stimulant such as Ritalin, plus an antipsychotic – possibly as a temporary

measure, rather than as a long-term prescription.

--

Ari Ne'eman

President

The Autistic Self Advocacy Network

http://www.autisticadvocacy.org

info@...

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