DSM-V Comes Out of the Closet

After a year of fomenting controversy, the American Psychiatric Association has taken the unprecedented step of making the draft of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) available online – and further, have actually asked for public input into the proposed disease categories on the website.

Probably the most striking and for many, surprising development is the decision not to include a formal pediatric bipolar diagnosis. This conception of childhood bipolar, first promulgated by prominent child psychiatrists such as Joseph Biederman, identified behaviorally difficult children as having a pediatric presentation of a condition which would normally present very differently in manic and depressive phases in adults. It is a diagnosis that usually leads those diagnosed to treatment with antipsychotic medications. The putative condition had been deeply divisive in the psychiatric community and the public at large, as it received extensive media attention, but nevertheless had become increasingly popular in recent years, even garnering several indication approvals from the FDA. As such, its exclusion from the DSM marks a major statement by the APA.

Of course, this does not mean that difficult children will go undiagnosed.  Instead, children who are wildly aggressive or oppositional may fall under the new category of “temper dysregulation disorder with dysphoria” (TDDWD). However, it is unclear whether this difference will lead to a change in prescribing patterns, as we need only remind ourselves that the treatment of bipolar in adults with antipsychotics is itself a relatively recent historical phenomenon. It does not seem to be a stretch to suggest that many GPs and psychiatrists may simply respond to cases of TDDWD with the same, newly off-label, prescription. Nevertheless, because TDDWD is a behavioral diagnosis, commentators have suggested that behavioral interventions are likely to now constitute the first line of treatment.

There are several other changes in the current draft.  A few interesting examples: the introduction of “psychosis risk syndrome”, a condition aimed at preventing the onset of psychotic disorders, has been included. New dimensional criteria will supposedly add greater personalization to a diagnosis, as the severity of patients’ experiences will be catalogued. “Internet addiction” was not included in the DSM-V, but other new conditions have been added, such as “hypersexuality,” which, in rough strokes, is when “a great deal of time is consumed by sexual fantasies and urges; and in planning for and engaging in sexual behavior”, and “binge eating disorder”, which occurs when one eats to the point of physical and emotional discomfort, at least once a week for three months. More precision on each of these conditions and other changes can be found at the official DSM-V website.

CJ Murdoch