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See Inside Scientific American Mind Volume 23, Issue 2

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

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

The APA says this pediatric entry will “provide a ‘home’ for these severely impaired youth,” but some critics worry doctors will dole out the diagnosis like lollipops to droves of tantrum-prone toddlers. The treatment is the same, despite the new name: a mixture of mood stabilizers, antipsychotics, anti­depressants and stimulants. —F.J.

Personality Problems
To a psychologist, a personality consists of persistent patterns of thought, emotion and behavior. Someone with a personality disorder has rigid and dysfunctional patterns that disrupt his or her ability to maintain healthy relationships. The current encyclopedia of mental illness, the DSM-IV, describes 10 such conditions. These include paranoid personality disorder—the inability to trust others and an irrational belief that people are out to get you—and narcissistic personality disorder, an exaggerated sense of self-importance, a need for constant admiration and excessive envy of others.

Suspiciously, between 40 and 60 percent of all psychiatric patients are diagnosed with a personality disorder, hinting that symptoms of at least some of these “disorders” resemble typical behavior too closely. In addition, psychiatrists often diagnose the same patient with more than one ailment, suggesting significant overlap. For example, people with both histrionic and narcissistic personality disorders insist on being the center of attention, take advantage of their families and friends, and have trouble reading others’ emotions.

The upshot: DSM-5’s editors nixed histrionic personality disorder. Paranoid, schizoid and dependent personality disorders are also gone. Your personality can still, however, be narcissistic, antisocial, avoidant, borderline, obsessive-compulsive or “schizotypal.” —F.J.

Good-bye to Asperger’s?
Certain behavioral quirks have long been thought to distinguish Asperger’s syndrome from other autistic disorders. “Aspies,” as people with this affliction sometimes call themselves, tend to develop intense fascination with very specific objects or facts—the wheels of toy cars or the names of constellations—in the absence of a general interest in, say, automotive mechanics or astronomy. Now the diagnosis will disappear, and Aspies may find an important part of their identity stripped away.

Currently Asperger’s is one of five so-called pervasive developmental disorders, along with autistic disorder, pervasive developmental disorder not otherwise specified (PDD-NOS), and the lesser-known Rett syndrome and childhood disintegrative disorder (CDD). All these problems are characterized by deficits in communication and social skills as well as by repetitive behaviors. Indeed, the APA has decided that four of the five disorders—autistic disorder, Asperger’s, CDD and PDD-NOS—are so similar that they should all be placed into a new category called autism spectrum disorder (ASD). Psychiatrists using the new DSM will give anyone on the spectrum a diagnosis of ASD, along with a rating of illness severity.

Children whom psychiatrists would previously have diagnosed with CDD fall at the more severe end of the spectrum. They typically experience an almost complete deterioration of social and communication skills starting sometime between the ages of two and 10. Asperger’s patients will land on the milder end. They generally do not show language delays and, in fact, often display excellent verbal skills. Rett syndrome, in which known genetic mutations stunt physical growth, along with language and social skills, is gone from the manual entirely. Ironically, the APA is eliminating it because a genetic test for the condition makes diagnosis so precise and straightforward. For now the DSM prefers to limit itself to a blunter diagnostic measure: behavior.

Statistical studies published in 2011 and 2012 confirm that the DSM-5 criteria for autism are more accurate than those penned in the DSM-IV. The revised guidelines practically guarantee that anyone told they have the disorder really has it. To qualify as autistic by the new manual, a patient must meet five of seven symptoms—a higher bar than the six-of-12-symptom cutoff in the DSM-IV.

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