DSM-V Proposals Spur Controversy
> 2/21/2010 5:54:37 PM

Chronic binge eating could soon become a diagnosable psychiatric disorder—and Asperger's Syndrome might disappear altogether.

The American Psychiatric Association recently released a list of changes proposed for the fifth edition of its trademark publication, the Diagnostic and Statistical Manual of Mental Disorders (DSM), and these announcements have prompted predictable waves of discord within the mental health community. Related debates have already grown so intense that the APA changed the DSM-V's official publication date in order to allow for a greater degree of public review and revision.

The most contentious changes include: the consolidation of all autism spectrum disorders under a single diagnostic heading; the official classification of binge eating as a form of mental illness; and a new set of criteria meant to counteract the over-diagnosis of bipolar disorder in children. Perhaps most controversial is the proposed adaptation of a series of "risk syndromes" for psychosis that would grant doctors the authority to pre-emptively diagnose subjects who they believe to face an enhanced risk of developing related disorders.

The predominant critique voiced by the proposals' opponents (including the writers of earlier DSM editions) concerns the belief that by adding new disorders, expanding the list of symptomatic criteria and complicating the diagnostic process, the new edition's authors will inspire overzealous prescription practices designed to benefit the pharmaceutical industry. APA officials, on the other hand, claim that their primary goal is to streamline and simplify the entire process so that subjects can receive effective care with as few inconveniences as possible.

It's true that the "risk syndrome" proposal could lead to a rise in antipsychotic prescription rates, but other developments seem designed to decrease the use of high-powered meds. For example, "temper dysregulation with dysphoria" has been introduced as a condition applicable to thousands of children who might otherwise be diagnosed with bipolar disorder. Proponents developed the "dysregulation" label because they believed that many of the American children who receive bipolar diagnoses will not actually benefit from related treatment plans. They argue that, while these kids display some of the same symptoms as those with bipolar disorder, they actually suffer from independent conditions requiring their own forms of treatment, and antipsychotic meds might do them more harm than good.

Some changes seem to affect only terminology, but they could have widespread reverberations. One such proposal involves changing substance abuse and dependence diagnoses into specified conditions like "alcohol-use disorder" that include the name of the relevant substance in their titles. The Autistic Spectrum Disorder changes also fall into this category. If the proposals go through, all autistic individuals will be listed under a single heading, and mental health professionals will dispense with subtypes like Asperger's Syndrome. Autism cases and related treatment plans vary so widely that such specifications may ultimately prove more confusing than helpful.

These developments may appear to have few real-world ramifications, but we've yet to consider how health insurance providers will respond. The health plans of thousands of Americans could well be affected by the mere rearrangement of DSM terms as insurance companies look for reasons to alter or deny coverage and pharmaceutical companies try to market their products for the treatment of any newly-coined disorders.

We're very pleased to note the inclusion of binge eating as a qualifiable condition. Recent surveys noted that chronic binge eating is more common than anorexia and bulimia combined, with proposed treatments including antidepressant meds and pharmaceutical appetite suppressants. "Internet addiction" is not yet ready for the DSM, but related clinical trials will almost certainly continue as the mental health community attempts to better define that 21st century affliction.

The now-delayed DSM-V won't be released until 2013, so we still have plenty of time to ponder the merits of the proposals mentioned in this post. The APA has posted the entire list in detail on its website. -Patrick Coffee

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