Mental Illness Manual Rewritten

Radical Changes Proposed for Diagnosing Mental Disorders

Medically Reviewed by Louise Chang, MD on February 10, 2010
From the WebMD Archives

Feb. 10, 2010 - The first draft of the new psychiatric manual -- the DSM-V, to be finalized in 2013 -- makes major changes in how a wide range of mental illnesses will be diagnosed.

Nothing is set in stone, says the American Psychiatric Association (APA) task force that is writing the new diagnostic "bible" -- the Diagnostic and Statistical Manual of Mental Disorders Version V, which will replace the DSM-IV written in 1994.

But some of the changes would be radical:

  • Say good-bye to Asperger's syndrome -- it would now be at the mild end of the "autism spectrum disorder."
  • Say hello to "temper dysregulation with dysphoria" or TDD, a new category of mood disorder for some children now lumped together with those suffering the more severe bipolar disorder.
  • Say good-bye to "substance abuse" and "substance dependence." Addiction disorders would be named after the addictive substance, such as "cannabis-use disorder" and "alcohol-use disorder."
  • A new category of "risk syndromes" would diagnose troubled teens with symptoms such as disordered thinking as having "psychosis risk syndrome."

Public comments are welcome until April 20, and the new diagnoses will be tested in three sets of field trials before the DSM-V becomes final.

The process has been anything but smooth. Two of the leaders of the task force that wrote the current manual have strongly criticized the way the new task force is doing its job. Back-and-forth commentaries between them and the leaders of the new task force and the APA leadership, published in the Psychiatric Times, have degenerated into personal attacks.

One expert with a foot in both worlds -- he is the editor of several DSM-IV publications and directed the DSM-V prelude project -- is Michael B. First, MD, professor of psychiatry at Columbia University and a researcher at New York State Psychiatric Institute.

"This is what always happens when something is new," First tells WebMD. "But overall, this is definitely not a paradigm shift. ... If this were the final draft, it would be time to call out the fire department. But now that these things are on the table, I'm hopeful that ideas that are possibly not the best will be taken away."

First likes a lot of what he sees in the new DSM-V. For example, he likes the new manual's emphasis on suicide prevention, and its effort not just to diagnose a disorder but to give a clearer idea of its severity.

On the other hand, First is disturbed by the proposed diagnosis of people as having risk syndromes for psychosis and dementia.

"Psychotic risk syndrome is the worst idea in the whole thing," First says. "Only 10% to 20% of people who meet the criteria for risk will actually become psychotic. That means that eight in 10 will get no benefit -- and what is the benefit? There is no way to prevent schizophrenia. And then there is the stigma. ... And the potential for normal people being captured under this rubric is high."

University of Miami psychiatrist Pedro Ruiz, MD, is president-elect of the World Psychiatric Association. As president of the APA from 2006 to 2007, he was involved in appointing members of the task force that wrote the new DSM-V. He's very positive about what the task force has accomplished.

"What we are trying to do is look at all the possible psychiatric diagnoses and to be sure that each one is real and based on scientific research," Ruiz tells WebMD. "It produces a lot of anxiety. Every time there are changes to the DSM, we get nervous. But it is very important that every once in a while we review the research evidence for all the diagnoses we use. And those that do not pass muster must be removed and we must add those that are new."

Ruiz notes that unlike previous versions of the DSM, the DSM-V task force includes members of the world committee and has the explicit intention of bringing U.S. psychiatric diagnoses into line with psychiatric diagnoses listed in the World Health Organization's diagnostic manual, which is undergoing simultaneous revision.

Ruiz notes that there likely will be valid criticisms made of some aspects of the DSM-V but says that the process will carefully evaluate each one.

"For this task force we selected the top people, not just the best in the U.S. but the best in the world," he says. "We have to give them an opportunity to do their work and see what they recommend. If there are errors, we have to give them the chance to correct them."

Ruiz's colleague at the University of Miami, psychiatry professor Ewald Horwath, MD, says the general theme of the DSM-V is to reverse the trend, begun with revision of DSM-I, to keep adding more and more new diagnoses.

"There was in the last couple of editions a feeling that the number of disorders was growing too much and too many behaviors were becoming medicalized," Horwath tells WebMD. "From what I have seen so far, I don't think that is happening in DSM-V. They are being careful to develop an appreciation for the complexities and dimensions of the current disorders rather than creating new ones."

That said, Horwath is happy to see the new TDD diagnosis that will, he says, keep children from being overdiagnosed as having bipolar disorder.

But don't take the experts' word for it. The proposed DSM-V has a web site,, where you can see the proposed diagnoses and -- until April 20 -- tell the task force what you think.

Show Sources


American Psychiatric Association: "DSM-5 Development."

News release, American Psychiatric Association.

Psychiatric Times, DSM-V series, 2009.

Michael B. First, MD, professor of clinical psychiatry, Columbia University; research psychiatrist, New York State Psychiatric Institute.

Pedro Ruiz, MD, professor of psychiatry, University of Miami Miller School of Medicine; president-elect, World Psychiatric Association.

Ewald Horwath, MD, professor of psychiatry, University of Miami Miller School of Medicine; chief of psychiatry, University of Miami Hospital and Jackson Memorial Hospital.

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