Psychiatry's "Bible" Gets an Overhaul [Preview]

Psychiatry's diagnostic guidebook gets its first major update in 30 years. The changes may surprise you


Fast Facts: A New Guide to Your Psyche
1.The fifth version of psychiatry’s bible, the Diagnostic and Statistical Manual of Mental Disorders, slated for publication in May 2013, represents the first substantial change to psychiatric diagnosis in more than 30 years.

2.In 2010 the American Psychiatric Association debuted a draft of the new manual on their Web site that has so far received 50 million hits from about 500,000 individuals, many of them critics.

3.The revised manual will very likely scrap psychiatry staples such as Asperger’s syndrome and paranoid personality disorder.

4.Additions to the diagnostic menu are likely to include an ailment for children marked by severe temper tantrums and for adults a type of sex addiction.

Psychosis Revisited
Schizophrenia is characterized by a tenuous grasp of reality, difficulty thinking and speaking clearly, and unusual emotional responses. In today’s diagnostic manual, the DSM-IV, this complex disorder is split up into the following “types”:

  • Paranoid: delusions and auditory hallucinations but normal speech and emotional responses.
  • Disorganized: erratic speech and behavior and muted emotions.
  • Catatonic: unusual postures and movements or paralysis.
  • Residual: very few typical symptoms but some odd beliefs or unusual sensory experiences.
  • Undifferentiated: none of the other types.

Yet another form of the illness is shared psychotic disorder: when someone develops the same delusions as a friend or family member with schizophrenia.

Soon you can forget all these variants. As with certain personality disorders, there is little evidence for the existence of these discrete categories. Catatonia, for instance—an intermittent “freezing” of the limbs—also accompanies bipolar disorder, post-traumatic stress disorder and depression. Therefore, psychiatrists say it makes little sense to call it a form of schizophrenia. Catatonia also does not respond well to the antipsychotic medications used to treat schizophrenia.

Even as it sheds these subtypes, the DSM-5 embraces novel forms of psychosis. The most contentious is attenuated psychosis syndrome, a cluster of warning signs that some researchers think precede the frequent delusions and hallucinations that characterize the full-blown disorder. Its purpose is to catch young people at risk and prevent this insidious progression. Critics contend, however, that two thirds of the children who qualify for the at-risk criteria never develop real psychosis and may unnecessarily receive powerful drugs [see “At Risk for Psychosis?” by Carrie Arnold; Scientific American Mind, September/October 2011]. After all, about 11 percent of us sometimes hear voices or engage in moments of intense magical thinking with little or no distress.

Another controversial addition is disruptive mood dysregulation disorder, a diagnosis for kids that carries less stigma than its predecessor, childhood bipolar disorder. Since about 2000, diagnoses of pediatric bipolar disorder have jumped at least fourfold in the U.S. Many psychiatrists, however, argued that their peers were mislabeling a condition that was not bipolar disorder at all and treating children with strong drugs before knowing what really ailed them.

Very few people younger than 20 develop true bipolar disorder, in which moods swing between depression and mania. The vast majority of the kids who received the label did not, in fact, oscillate in this way. Instead they were in a bad mood all the time and frequently exploded in anger and physical violence, even in response to a minor offense. Because of these differences, disruptive mood dysregulation disorder describes a child (younger than 10) who is constantly irritable and has extreme temper tantrums about three times a week.

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This article was originally published with the title "Redefining Mental Illness."

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