For more than 11 years, the American Psychiatric Association (APA) has been laboring to revise the current version of its best-selling guidebook, the Diagnostic and Statistical Manual of Mental Disorders (DSM) (see "Psychiatry's Bible Gets an Overhaul” in Scientific American MIND). Although the DSM is often called the bible of psychiatry, it is not sacred scripture to all clinicians—many regard it more as a helpful corollary to their own expertise. Still, insurance companies in the U.S. often require an official DSM diagnosis before they help cover the costs of medication or therapy, and researchers find it easier to get funding if they are studying a disorder officially recognized by the manual. This past December the APA announced that it has completed the lengthy revision process and will publish the new edition—the DSM-5—in May 2013, after some last (presumably minor) rounds of editing and proofreading. Below are the APA's final decisions about some of the most controversial new disorders as well as hotly debated changes to existing ones, including a few surprises not anticipated by close observers of the revision process:

Hoarding is now an official disorder
Hoarding is the excessive accumulation of stuff—often stuff that most people would throw out or give away, such as junk mail, unworn clothes, old newspapers and broken tchotchkes. Some people hoard animals or obsessively collect a particular item, such as fabric. Many hoarders store their collections in their homes, but some use their cars or offices instead. Although the stuff piles up, commandeering all living spaces save for narrow "goat trails," hoarders refuse to get rid of anything. In some cases, hoarders simply do not recognize all the chaos and clutter as a problem. In past editions, the DSM regarded hoarding as a symptom of obsessive-compulsive disorder (OCD). Now, in a move well supported by a variety of research, the DSM-5 makes hoarding a disorder in its own right.

Studies published in the last 10 years have emphasized that many hoarders do not have any other symptoms of OCD and that hoarding may be more common than OCD in the general population. Investigations have also suggested that although OCD and hoarding can co-occur, they are genetically and neurologically distinct. Parents and siblings of hoarders show higher rates of hoarding than do first-degree relatives of people with OCD, for instance, and hoarding seems to be inherited as a recessive trait, whereas the compulsive checking and organizing that characterizes OCD is dominant. Further, although some antidepressants, such selective serotonin reuptake inhibitors (SSRIs), and cognitive behavioral therapy often help OCD, their success is much more mixed in changing hoarding behaviors.

Neuroimaging studies support the new diagnosis as well. They have revealed that when hoarders make decisions about what to keep and what to throw out, their brain activity is markedly different from that of people with OCD and people without a mental disorder. In such situations, hoarders take far longer to make up their minds and show more activity in the anterior cingulate cortex, a brain region that is important for decision-making, as well as higher activity in the insula, an area of the brain that helps us interpret our emotions and physiological responses. Hoarders, it seems, form strong emotional attachments to objects that most people would not hesitate to chuck out.

Renaming addiction and introducing gambling disorder
The DSM has long avoided the word “addiction.” Instead, the DSM-IV—the current edition and predecessor of the new manual—discusses substance abuse and substance dependence. According to the fourth edition, substance abuse refers to repeated drug use that creates problems at work or school and in one's social life—binge drinking in college, for example. In contrast, the DSM-IV's definition of substance dependence is what the phrase "drug addiction" brings to most people's minds: an inordinate amount of time spent acquiring a drug, increased tolerance, recurrent physical or psychological harm as a result of drug use, failed attempts to stop taking the drug and symptoms of withdrawal.

8 Comments

1. 1. Franklinskid 02:45 PM 1/28/13

   I see nothing here addressing Complex Post Traumatic Stress as a disorder or syndrome or recognizing it at all. Did that not make the cut for this latest manual, or just not for this article?

   Reply | Report Abuse | Link to this

2. 2. Geologon 05:18 AM 1/29/13

   I suspect that these manuals tend to disregard many disorders, as insurance companies prefer it that way.

   Reply | Report Abuse | Link to this

3. 3. alice w 07:22 AM 1/29/13

   A travesty of scientific evidence
   
   APA does not seem too worried about the serious risk of false positives, which may have dire negative consequences such as unsuitable drugs, professional exclusion, social labelling.
   
   Reads like a conspiracy between insurance companies and mental health professionals, in which mess people with serious and curable syndromes may well be missed.
   

   Reply | Report Abuse | Link to this

4. 4. stuball21 08:20 AM 1/29/13

   You didn't discuss the changes in the eating disorder criteria that are also rather controversial.

   Reply | Report Abuse | Link to this

5. 5. Diesel67 08:01 PM 1/29/13

   I suspect that this manual will continue to pathologize normal variants of the human personality, and stigmatize those bearing them. While in school, I tended to fidget and look out the window. Now I'm told that that's a symptom of "attention deficit disorder" for which powerful psychoactive drugs are indicated. Never mind that I maintained a 90+ average throughout. Never mind that our ancestors needed a periodic fix on their surroundings if they expected to be the diner and not the dinner. Never mind that our ancestors made their living running for hours on end and killing large animals with primitive weapons. Nothing in biology makes sense except in the light of evoluton, but that doesn't stop fat pigs behind desks from dispensing psychiatric diagnoses to robust healthy rambuntious kids.
   I was never good at matching names with faces or interpreting body language. Now I'm told those are symptoms of Asperger's Syndrome; never mind that I compensate very well with written and spoken language and I do not consider myself sick.
   Hardly a day passes when I do not think of President Kennedy. This does not affect my functioning in the least, except on November 22, the anniversary of his assassination, when I am not in the mood for entertainment or Thanksgiving dinner. Now I'm told I have "complicated grief," but all I experience is natural grief for a political idol the like of whom I do not expect to see again in my lifetime.
   All this is giving me (complicated?) grief, and calls to mind the abuse of psychiatry by the Soviets to quell political dissent. If you have a biochemical, brain imaging or other definitive test for your diagnosis - fine. Otherwise, throw away the cookie cutter and celebrate humanity's pizzazz.

   Reply | Report Abuse | Link to this

6. 6. American Muse 03:02 PM 1/30/13

   Geez! Another bestseller for APA. More money folks.

   Reply | Report Abuse | Link to this

7. 7. Michael M 12:15 PM 1/31/13

   Unfortunately, commentors are not familiar with the body of work done on DSM, not to mention the study required to become conversant with psychology.
   
   To address only a couple misunderstandings:
   DSM is a large manual, far beyond the 7 extremely short pages of this article.
   
   Unedited internet comments on subjects which take decades of study to develop coherent understanding are particularly inappropriate.
   
   Although I've studied psychology and related disciplines for sometime, I did not do so for therapeutic reasons. That said, almost no comment on the subject on this or other websites takes into account the real empathy which those involved in the therapeutic disciplines and the development of DSM, as well, have for others, ALL others.
   SA is not a panacea site such as MSN Health or any site in which glib curealls are offered for illness or personal difficulties or desires. It is a digest of information which might be used as portal to specific peer-reviewed literature for those who seek knowledge of rigorous research encompassing the lifetimes of hundreds of thousands of dedicated individuals.
   
   I am framing my criticism in terms of a social problem: failure of many in society to respect others, and promoting this disrespect of individuals, groups, and disciplines of professional dedication (ANY discipline, whether within their own culture or outside of it), through using internet comment as aggressive outlet for personal frustration elsewhere.
   
   Commentors might look more insightuflly into their own motivations before attacking others.
   

   Reply | Report Abuse | Link to this

8. 8. endo_alley 05:37 PM 5/6/13

   How about G.A.S. ? Guitar Acquisition Syndrome? http://www.steelydan.com/gas.html
   Luckily I've recovered. Sadly many haven't.

   Reply | Report Abuse | Link to this