DSM-V could add, delete diagnoses



David Greenfield, Ph.D., director of the Center for Internet and Technology Addiction in West Hartford, Conn., says that the Internet compounds problems such as gambling and sex addiction. (photo by Tom Croke)

By Ami Albernaz

The DSM-V is due out in 2012, but there's already no shortage of speculation on which diagnoses might be added and which ones might get tossed. While some of the diagnoses to have been mentioned are clearly a reflection of the times, the larger discussion is a reminder of the difficulty and delicacy involved in deeming a disorder a disorder.

Published reports have highlighted five diagnoses whose fate is now being determined. Those that could debut include binge eating disorder; behavioral addiction or excessive shopping, sex, or computer usage that may "mimic the behavior of drug addicts;" and prolonged or complicated grief, protracted mourning after the death of a loved one. (The paraphilias, or "intense sexual urges involving animals, children, non-consensual sex, suffering, and humiliation" and gender-identity disorder might be scratched).

DSM "watchers" question whether some conditions are indeed pathological or are merely personality quirks. In a blog he writes for Psychology Today, Christopher Lane, Ph.D., author of the book "Shyness: How Normal Behavior Became a Sickness" and a literature professor at Northwestern University, mentioned apathy disorder and posttraumatic embitterment disorder as two other conditions to have been floated.

"These are such widespread, run-of-the-mill concerns that it truly beggars belief that they could soon be adopted as formal mental disorders," Lane says via email. No final decisions have yet been made, says William Narrow, M.D., M.P.H., research director of the American Psychiatry Association's DSM-V Task Force, but the work groups that will ultimately make those calls are taking care not to "medicalize normal human experience."

"To be a behavioral or psychological syndrome, there needs to be some sort of clinically significant distress or functional impairment associated with it," Narrow explains. "The impairment can't be due to conflict with society or to societal prejudices."

Critics of behavioral addiction say the disorder might really be a form of depression or obsessive-compulsive disorder. David Greenfield, Ph.D., director of Center for Internet and Technology Addiction in West Hartford, Conn., argues that some people "didn't have a problem until the addiction," and that in any case, the nature of the Internet compounds problems such as gambling and sex addiction.

"[The Internet] creates a synergistic experience," he says. "It facilitates, amplifies and enables those behaviors, because of the ease of access, anonymity and dissociative capacity that the Internet produces."

The addition of binge-eating disorder, meanwhile, would be uncontroversial to psychologists who treat eating disorders, says DeAnn Ewart, Ph.D., a psychologist in Brookfield, Conn.

"I think any professional would argue that there is a binge eating disorder," she says. "Right now there are big lump categories, like anorexia and bulimia. � I think [a binge eating disorder diagnosis] would be helpful in making distinctions and in clinically applying information."

Some people incorrectly assume that diagnoses are well-defined and concrete, waiting, so to speak, to be discovered, says George Bonanno, Ph.D., a clinical psychology professor at Columbia University. The fact that they're not, he adds, doesn't make them less valuable.

"The DSM diagnoses are cultural tools. They're on a continuum," he says. "But you need a line somewhere to say what's normal behavior and what's disordered."

A grief expert, Bonanno believes prolonged or complicated grief would be a useful addition to the DSM. He describes this form of grief as a "yearning" and sense of "utter aloneness" that goes beyond PTSD or depression. In studies he and colleagues conducted of people who had lost a loved one, measures of prolonged grief explained more of the outcome variance than did the other two diagnoses, he says.

"It explained people's heart rate when they talked about the loss; it explained how well friends thought they were doing; it explained functioning - it was very predictive," he says.

The DSM-V will include dimensional assessments in order to add depth to diagnoses and offer a more comprehensive view of patients, Narrow says. Many clinicians have complained about the yes-no type of categorization in the previous manuals, he acknowledges.

"If a person meets the criteria for major depressive disorder, we know the person will almost always have considerable anxiety, maybe sleep problems," he says. "The DSM currently doesn't have a good way to document those associated disorders, unless you go through the diagnostics for those other disorders. We'll give clinicians the opportunity to rate symptoms for these associated conditions when they start treatment and to follow changes in symptoms to see if the treatment is working."

The DSM work groups will start clinical field trials of the diagnoses under consideration within the next couple of months. (Task force updates can be found at www.dsmv.org.)

Perhaps not surprisingly, given the advances in neuroscience, behavioral science and epidemiology since 1994, the new manual will incorporate more data and will be more empirically based than previous manuals, Narrow says.

"Unfortunately, we're not going to be able to incorporate some findings in neuroscience and genetics because we still need a few more years of research," he says. The task force aims to develop a so-called "living document" that would make room for newly substantiated findings, rather than put them on hold until the next DSM is published. In the shorter term, psychologists agree, having new diagnoses in print would encourage research and spur better treatment. "There's a myriad of ways that having a label would help," Greenfield says. "There would be more medical school research, more doctoral dissertation research... and that can only be a good thing."