This new trend outraged a large segment of the psychiatric community. Most of the so-called bipolar kids—some of whom subsequently took mood stabilizers and antipsychotics with serious side effects—did not have a form of bipolar disorder, many psychiatrists argued. They probably had a different illness altogether. Instead of vacillating between mania and depression, they were irritable most of the time and often erupted in fits of rage and physical violence incommensurate to whatever supposed offense set them off. So the APA decided to create a brand new diagnosis to accommodate these misunderstood children: disruptive mood dysregulation disorder. To meet the criteria, a child between six and 18 must "exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year."
Critics such as Stuart Kaplan of the Penn State College of Medicine, clinical social worker and pharmacist Joe Wegmann, and Allen Frances, professor emeritus at Duke University and chairman of the DSM-IV Task Force, worry that psychiatrists will confuse temper tantrums for a mental disorder and thus continue what they see as a trend of overdiagnosis and overmedication. David Axelson of the University of Pittsburgh put the DSM-5 disruptive mood dysregulation criteria to the test using several years' worth of data collected from 706 children and concluded that the new disorder was not very useful. First, it confusingly overlapped with—and was often difficult to distinguish from—two established diagnoses: oppositional defiant disorder and conduct disorder. Furthermore, a diagnosis of disruptive mood dysregulation in childhood was not a good predictor of future mental health issues, specifically depression and anxiety. Many observers hoped that this research, published in late 2012, would change the APA's mind, but the committee decided to keep disruptive mood dysregulation disorder in the DSM-5.
The personality disorders chapter remains disordered
For decades psychiatrists within and without the APA have called for a complete overhaul of the way clinicians describe and diagnose personality disorders because of obvious flaws. For one thing, many criteria for the 10 personality disorders listed in the DSM overlapped, resulting in so many patients with multiple diagnoses that the validity of certain disorders came into question: Did some of these disorders simply not exist outside the pages of the DSM? Histrionic and narcissistic personality disorders, for example, are both characterized by a need to be the center of attention, a willingness to take advantage of families and friends, and difficulty reading other people's emotions. Additionally, psychiatrists began to rely too heavily on “Personality Disorder–Not Otherwise Specified,” suggesting that some patients had personality problems that were not adequately defined by the DSM in the first place.
More fundamentally, clinical psychologists have increasingly come to realize that people do not categorically have or not have certain problematic personality traits—rather, these characteristics vary in strength from person to person. Therefore, instead of making a diagnosis by looking for the presence or absence of maladaptive personality traits, clinicians should measure the severity of such traits to help determine, in the context of a patient's overall mental health, whether and how the person should be treated.
Although the members of the DSM-5 work group tasked with redefining personality disorders did not agree about everything—and two members, Roel Verheul and John Livesley, resigned in frustration—the team drafted a relatively well-received proposal for serious revisions. The proposal eliminated four redundant disorders and, overall, adopted a much more nuanced view of personality than espoused by earlier versions of the DSM, encouraging thorough interviews to assess how well an individual maintains a coherent sense of self and how he or she interacts with others, rather than trying to slot someone into one of 10 categories based on a few supposedly telltale symptoms.