New DSM changes categories for autism, eating disorders

Proposed changes to the nation's leading manual on mental disorders call for improved criteria for eating disorders, new categorizations of learning disorders and an introduction of tools to help health professionals better identify patients at risk for suicide.

The American Psychiatric Assn. released its draft of criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders on Feb. 10. The last edition, DSM-IV, was published in 1994, with revisions made in 2000. DSM-5 is scheduled for release in May 2013.

In the interim, the APA will conduct three phases of field trials to test some of the proposed diagnostic criteria in clinical settings. The final text must be approved by APA's assembly and board of trustees. Comments on the proposed changes will be accepted on the APA's Web site until April 20.

The proposals for DSM-5 have sparked concern among some members of the psychiatric community.

One key issue is a new single diagnostic category, "autism spectrum disorders," that would incorporate autistic disorder, Asperger's syndrome, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified.

Other issues cited include a fear that healthy patients may be lumped into newly created disorders, such as binge eating. Some also have perceived a lack of openness with the field trials.

The development process has been transparent, said vice chair of the DSM-5 task force, Darrel Regier, MD, MPH. He encouraged physicians to review the proposals and provide input.

"We want them to give us their best advice for scientific support for these changes and tell us what they think are the clinical implications for feasibility and ease of use of these in their patients," Dr. Regier said.

Concerns over this edition did not come as a surprise to Michael B. First, MD, editor for DSM-IV.

"Any proposal [to change the DSM] should in fact cause a stir because it has potential to cause such a huge impact on everyone's lives," said Dr. First, professor of clinical psychiatry at Columbia University Medical Center and a research psychiatrist at New York State Psychiatric Institute. He was involved in developing research agendas for DSM-5.

In 2007, about 160 clinicians and researchers began examining seven years of scientific reviews and conducting additional focused reviews.

"A major focus turned out to be ... clinical utility and validity. How do we assure that the criteria is as clinically useful as we can make it?" said B. Timothy Walsh, MD, professor of psychiatry at Columbia University Medical Center and director of the Division of Clinical Therapeutics at New York State Psychiatric Institute.

Key revisions

Dr. Walsh, chair of the eating disorders work group for the manual, said many people with anorexia or bulimia do not meet all criteria in DSM-IV, leaving them grouped into the category "eating disorder not otherwise specified." That broad description conveys little information, he said.

Dr. Walsh and his colleagues also proposed that binge eating be recognized as a freestanding disorder, rather than a listing in the manual's appendix, as it is now.

"It's not just the occasional second helping of dessert." Rather, Dr. Walsh said, the disorder includes eating more food than most people would at least once a week, feeling out of control during the episode and feeling distressed about the eating pattern.

Other recommendations include a "behavioral addictions" category, in which gambling will be the sole disorder, and new suicide scales, including one specifically for adolescents.

These scales feature a series of questions clinicians can ask a patient who has attempted suicide to determine risk for another attempt, according to David Shaffer, MD, a member of the disorders in childhood and adolescence work group for the manual and a professor of psychiatry and pediatrics at Columbia University Medical Center in New York.

Dr. Shaffer said the suicide scale is particularly key for adolescents, who are more likely than adults to make a suicide attempt but less likely to die from it. "Anyone in an emergency room sees so many teenagers who made a suicide attempt. ... The idea was to come up with some kind of indicator as to which of these many kids you really have to be careful with."