When psychiatrists diagnose mental illness, they turn to an unwieldy book called the "Diagnostic and Statistical Manual of Mental Disorders," or DSM for short.
First published in 1952, the tome also is used as a standard by researchers, the health insurance industry and pharmaceutical companies.
But the American Psychiatry Association is now in the middle of a historic and controversial revision of its bible. The fifth and highly anticipated edition, DSM-5, has sparked dissension among psychiatrists and generated more than 8,000 public comments on topics ranging from sexual- and gender-identity issues and anxiety disorders to mind-body problems.
The proposed revisions are "based on the most rigorous and up-to-date scientific findings available," said Dr. Darrel Regier, the DSM-5 task force vice chairman. Inclusion, meanwhile, "means that a mental illness is more likely to be a target of research, which ultimately will improve our understanding how best to diagnose and treat psychiatric disorders," he said.
Critics say some of the new entries broadly extend some definitions of mental illness and lower thresholds for some existing disorders, which will result in higher rates of diagnoses. That, they argue, "could result in massive overtreatment with medications that are unnecessary, expensive and often quite harmful," Dr. Allen Frances, chairman of the DSM,-IV task force, wrote in the Psychiatric Times.
In response, the American Psychiatry Association, which publishes the manual, has increased the transparency of the process; All the proposals can be found at dsm5.org. It has extended the publication date to May 2013.
Today's DSM defines 238 mental illnesses. Among the proposed changes for DSM-5 are a single diagnosis for autism and related disorders, the classification of binge eating as a medical condition, and the inclusion of the category "nonsuicidal self-injury" to distinguish those who cut themselves from those who are attempting suicide. Here's a small sample of some proposed changes:
AUTISM SPECTRUM DISORDER
The change: Creates a single diagnosis
Since doctors approach patients on the spectrum in different ways, a child might get three different diagnoses. "Previously, the criteria were equivalent to trying to 'cleave meatloaf at the joints,'" the working group wrote in its rationale for the change. Instead of "autistic disorder," the name would be autism spectrum disorder; it would include autism, Asperger's disorder, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified.
The change: Lowers threshold
If you eat a large amount of food at one time, feel like you can't stop and are disgusted, embarrassed or feel depressed by how much you ingested, you meet a few of the criteria for binge-eating disorder.
Included in the appendix of the current DSM, binge eating has been compared with anorexia nervosa, bulimia nervosa and obesity. But due to its distinct characteristics, it would become a free-standing diagnosis.
What concerns some is that bingeing is a fairly common behavior. The diagnosis would apply to those who binge, on average, at least once a week for three months. In the current DSM, the frequency was at least two days a week for six months; the lower threshold could medicalize normal behavior, critics say.
The change: Distinguishes self-harm from suicidal tendencies
People who injure themselves by cutting, burning, stabbing, hitting or excessive rubbing don't necessarily want to die. Cutters, for example, may feel a sense of relief, which is very different from a highly stressed individual who seeks to end his life, said Dr. Mark Olfson, a professor of clinical psychiatry at Columbia who is not involved with the revisions.
"Currently, a person who comes to ER after making a suicide attempt, say by intentionally swallowing pills with the intent to die, is diagnosed with the same disorder as someone who makes a small cut to his or her wrist to relieve anxiety and has no intent to die," said Olfson.
His research has found emergency room doctors often don't evaluate the mental health of patients who intentionally harm themselves: "Right now, whether it is suicidal or nonsuicidal self-injury, it is all viewed as 'intentional self-injury,' but they are clearly different groups."
People who injure themselves without an intention to die don't necessarily need to be treated in the hospital or with the same sense of urgency as those with suicidal self-injury, Olfson said. If there's any risk to drawing the distinction between suicidal and nonsuicidal self-injury, he added, it would be that doctors might then downplay the seriousness of nonsuicidal self-injury. Even though that group of patients does not pose an urgent and life-threatening risk, research has shown that people who injure themselves without an intent to die often have accompanying serious mental health problems and benefit from being treated.
RESTLESS LEGS SYNDROME
The change: A new diagnosis
As many as 10 percent of Americans may suffer from restless legs syndrome, an urge to move the legs accompanied by throbbing, pulling, creeping, or other unpleasant sensations, according to the National Institute of Neurological Disorders and Stroke. The symptoms occur primarily at night when a person is relaxing. Sleep is often profoundly disturbed. It's commonly treated with medication.
Also being considered:
The following suggestions are also under review.
Apathy syndrome: Loss of motivation not due to emotional distress, intellectual impairment, or diminished consciousness.
Body integrity identity disorder: Individuals ask for an elective amputation that's not medically necessary.
Male-to-eunuch gender identity disorder: Men seek castration to align with their brain sex, which is neither male nor female.
Complicated grief disorder: More than a year after a loss, a person still feels pangs of severe emotion, empty, has unusual sleep disturbances and excessively avoids tasks that may be reminiscent of the deceased.
Developmental trauma disorder: Youngsters who experience serious and repeated traumas ranging from abuse and neglect to living with caregivers impaired by illness, alcohol or depression.
Internet addiction: Excessive computer use that interferes with daily life.
Melancholia: A form of depression accompanies by a complete loss of pleasure in all or almost everything. Even when something good happens, the individual's mood does not improve.
Parental alienation disorder: This term, coined in the 1980s, describes a disorder in which a child continuously belittles and insults a parent without justification, often due to indoctrination by the other parent usually as part of a child custody dispute.
Seasonal affective disorder: A type of depression that occurs at the same time every year. Symptoms often start in the fall and may continue into the winter months, sapping your energy and making you feel moody. It is not yet specifically listed under mood disorders in the DSM.
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