Published online 10 February 2010 | Nature | doi:10.1038/news.2010.60


Changes proposed to key psychiatry manual

Controversial revision alters diagnostic definitions.

The American Psychiatric Association is unveiling a host of suggested changes to its influential Diagnostic and Statistical Manual of Mental Disorders (DSM). Proposed revisions include uniting several autism-related diagnoses, including Asperger's syndrome and Rett's syndrome, under the umbrella of autism spectrum disorder; introducing a diagnosis of gambling addiction; and eliminating the distinction between alcohol dependence and alcohol abuse.

The proposals, to be posted to the association's website on 10 February, will be open for public comment until 20 April. In July, the association will begin testing the changes in academic centres and hospitals by asking psychiatrists to feed back on how their work would be different using the new diagnoses. The revised manual, known as DSM-V because it is the fifth edition, is to be released in May 2013.

The DSM is used to diagnose patients and guide research, primarily in the United States. Subtle changes to past editions have been credited with wide-reaching effects such as increasing the number of children diagnosed with autism or allowing accused criminals to go free on the basis of a psychiatric diagnosis. As a result, revising the manual can be a delicate issue.

The current revision has been particularly troubled (see Psychiatry manual revisions spark row). Rumours suggested that the new edition might include such controversial diagnoses as addiction to food, shopping, or the internet.

The process, too, came under fire. Last March, Jane Costello of Duke University in Durham, North Carolina, resigned from the work group on childhood and adolescence, saying that she felt pushed to make changes that were not adequately backed by research.

Months later, the group lost another member, Fred Volkmar of Yale University in New Haven, Connecticut. "I found myself increasingly uncomfortable with the process," he says. In the past, he says, proposed changes were often published early in peer-reviewed journals.

Changes under fire

One new proposal that concerns Volkmar is the decision to lump autism-related disorders into a single category called 'autism spectrum disorder'. The changes reflect recent autism research, he says, but he is concerned that the change was proposed without adequately considering its social ramifications. A diagnosis of 'autism' is often required to obtain social services such as access to special education programmes. "I worry that there'll be some potential for diluting the pool of services for children really in need," says Volkmar.

Other proposed changes run the gamut from eliminating the term 'mental retardation' — to be replaced with a new 'intellectual disability' category — to introducing diagnoses such as 'psychosis risk syndrome' and 'mild neurocognitive disorder', which are designed to catch patients in the early stages of a disorder. Early diagnosis could help target patients for early intervention, says William Carpenter, chair of the psychotic disorders work group and director of the Maryland Psychiatric Research Center in Baltimore.

But he acknowledges that such categories can lead to diagnosing many people who will not go on to develop a full-blown condition such as Alzheimer's disease. To avoid this, the categories include only those patients who seek help specifically for the symptoms associated with these conditions.


Another proposed change is to eliminate the distinction between alcohol abuse and alcohol dependence. "I think clinicians who deal with alcohol problems are not going to be too happy that they can't make that distinction," says psychiatrist Robert Spitzer of Columbia University in New York.

But Nora Volkow, director of the National Institute on Drug Abuse in Bethesda, Maryland, says the change in the alcohol definition is a step in the right direction, because abuse was previously seen as a necessary step on the path to dependence. "Individuals can become dependent without passing through the abuse phase," she says. "The data are clear on that."

Not all proposed changes made it in. Volkow, for instance, had lobbied to include addiction to food, which did not make the final cut because the working group felt there is still insufficient scientific evidence to back the diagnosis. It remains to be seen whether the other proposed revisions will survive the public comment period. 

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