The controversial revision to psychiatrists' "bible" of diagnostic criteria has finally arrived. The American Psychiatric Association released its fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or dubbed simply as the "DSM-5." 
 
 The manual's release was coincided with the APA's annual meeting that kicked off May 18 in San Francisco. 
 
 The first major revision to the manual in almost two decades, the new DSM has been met by controversy since reports of proposed changes started to crop up last March. 
 
 Revisions to be announced soon to D.S.M. 
 
 Doctors often utilize the DSM to diagnose mental health disorders in patients that meet a specific set of criteria. 
 
 Among the major changes that garnered the most controversy was dropping Asperger's syndrome, child disintegrative disorder and pervasive developmental disorder not otherwise specified (PDD), and included them under the blanket diagnosis of autism spectrum disorder. 
 
 Revisions were also made to diagnostic criteria for mental health disorders including schizophrenia, bipolar disorder, dissociative identity disorder and depressive disorders. 
 
 For example, in the last version of the manual, the 1994 DSM-IV, there was was an exclusion criterion for a major depressive episode that was applied to people with symptoms of depression lasting less than 2 months following the death of a loved one. The DSM-5 removed this after the APA realized since the last version that grief can last up to two years, and bereavement can be a severe psychological stressor that triggers depression, rather than an exception. 
 
 Besides worrying some mental health advocates over concerns changes in their diagnosis would affect their abilities to get treatment for state funding, the manual's release also pitted the government's National Institute of Mental Health (NIMH) and the American Psychiatric Association (APA), 
 
 NIMH director Thomas Insel wrote in a statement in early May that the NIMH felt the proposed definitions for psychiatric disorders were too broad and ignore smaller disorders that were lumped in with a larger diagnosis. 
 
 "The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever," he wrote. 
 
 The government agency said it would use a different classification system, the Research Domain Criteria (RDoC) project, instead for its studies. 
 
 The NIH and APA released a joint statement on May 13, saying that "patients, families, and insurers can be confident that effective treatments are available and that the DSM is the key resource for delivering the best available care." But, the statement also said, "The National Institute of Mental Health (NIMH) has not changed its position on DSM-5." 
 
 A petition was also started by doctors to protest the new DSM. 
 
 "Psychiatrist's bible" changes: Doctor talks controversy 
 
 One vocal critic, Dr. Allen Frances, who co-authored the DSM-IV, told CBS This Morning on Thursday that we are over-treating people in this country who are "basically well" and are "shamefully neglecting" people with mental disorders who are really sick, including one million people in prison with psychiatric disorders. The new manual, he said, is too loose for its diagnoses. 
 
 He said the average diagnosis is being given by a primary care doctor in a seven minute visit. 
 
 "People who are basically normal are getting all kinds of medicine that they don't need that makes them worse and it is a terrible drain on the economy," Frances said. 
 
 "I'm very curious to see what happens because as you know there's kind of this tension between the DSM and some of the new NIMH initiatives," Dr. James Murrough, an assistant professor of psychiatry and neuroscience at Mount Sinai Hospital in New York City, told CBSNews.com Murrough was not involved in the new DSM, but will be presenting research at the APA meeting this weekend. 
 
 He said by now, some psychiatrists had hoped the new DSM would contain more information about scientific tests or scans for psychologists or psychiatrists to help aid their diagnoses. But, he added the new version doesn't appear to look very different from the last one. 
 
 "I think everyone is kind of disappointed that we don't have that yet," he said. 
 
 More information about the DSM-5 can be found on the APA's website. ||||| Patrick Tourneboeuf / tendance floue A sofa in a psychoanalyst's office, Paris, France. 
 
 On Saturday, the American Psychiatric Association (APA) finalized a 13-year process of revising the Diagnostic and Statistical Manual of Mental Disorders, commonly known as the DSM, the most important book in the field of mental illness. The DSM attempts to designate and code all the ways our minds can go awry. It defines depression, anxiety, schizophrenia — as well as more than 300 other problems from obsessive-compulsive disorder to stuttering to fetishism. Insurance companies require DSM codes for reimbursement, and the National Institutes of Health require them for research grants. It’s no exaggeration to say that the new DSM — the fifth full edition, one that more than 1,500 mental-health experts help write — will change the world of mental health. 
 
 Here are some of the biggest changes: 
 
 1. Autistic disorder will become autism-spectrum disorder. That spectrum will incorporate Asperger’s syndrome, which generally involves milder forms of autism’s social impairments and previously had its own code number (299.80). To guide clinicians, the DSM will include specific examples of patients meeting criteria for the different disorders making up the spectrum, from autistic disorder to Asperger’s, childhood-disintegrative disorder and pervasive developmental disorder (not otherwise specified). Combining autism and Asperger’s is especially controversial partly because autism can be so much more serious than Asperger’s. Although some autistic people function extremely well (the livestock expert Temple Grandin has helped change her field), others affected by the disorder need lifelong care for basic needs. The change will likely cause considerable debate, however, since the diagnosis is a requirement for access to some of the educational and social services that make up this care, and it’s not clear yet how the change in definition will affect such eligibility in the future. 
 
 (MORE: DSM-5 Debate: Committee Backs Off Some Changes, Reopens Comments) 
 
 2. Binge-eating disorder will be moved from DSM‘s Appendix B — a category of proposed conditions that require “further study” — to a full-blown illness in the main part of the book. The shift will create a significant new market for mental-health professionals who will now be able to apply for insurance reimbursement for patients who binge eat. A major criticism of considering binge eating a distinct disorder is the difficulty in distinguishing whether consuming an entire pint of Ben & Jerry’s could be a sign of depression or anxiety rather than an illness of its own. But in recognizing recent research that suggests that there are unique features to binge eating involving distorted-body-image issues, the APA in its press release on the DSM changes says that “the [binge-eating-disorder] change is intended to better represent the symptoms and behaviors of people with this condition.” 
 
 3. The new DSM will remove the exception for bereavement from the definition of depression, which means psychiatrists will be able to diagnose depressive disorder even among those who have just lost a loved one. For years, skeptics have criticized the APA for its expansive meaning of depression; now that definition is even broader. 
 
 4. Continuing the expansion of diagnostic criteria, the new DSM will also include a controversial new diagnosis called “disruptive mood dysregulation disorder (DMDD),” a label that can be attached to “children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year.” Earlier this year, the Huffington Post called DMDD the “tantrum diagnosis,” and a blogger for Wired warned that the new disorder “could be anything, like the meltdown when the shoes can’t be found, the homework got lost, or the braids aren’t quite right.” But the APA says the new diagnosis “is intended to address concerns about potential over-diagnosis and over-treatment of bipolar disorder in children.” 
 
 (MORE: The Trouble with Talk Therapy) 
 
 5. DSM-5 will also incorporate the extremely rare disorders of excoriation (skin picking) and hoarding. The current DSM does list trichotillomania (obsessive hair pulling), but adding reality-show problems such as skin picking and hoarding has bolstered criticisms of diagnosis creep. Hoarding was previously considered a form of obsessive-compulsive disorder. 
 
 What will not be added to the DSM is hypersexual disorder — sex addiction — even though many APA members argued for its inclusion. According to one member of the APA’s board of trustees: “The evidence just wasn’t there.” Other mental-health professionals note that the DSM is subject to political influence. “This is a huge moneymaker for the American Psychiatric Association,” says Marsha Linehan, a University of Washington professor and a leading expert on personality disorders. The decisions reflect the votes of the APA’s board of trustees; the entire membership will vote on the revisions later in the spring, but experts don’t expect additional alterations. Which means that the approval this weekend of DSM-5 ends years of editing but begins years of debate. 
 
 MORE: What Counts as Crazy? ||||| A copy of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV-TR) is seen. The APA announced it would drop Asperger's syndrome from its upcoming fifth edition of the psychiatrists' handbook, among the first changes to the manual in about 20 years. / Amazon.com 
 
 Asperger's syndrome will be dropped from the latest edition of the psychiatrist's "bible," the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5. 
 
 The American Psychiatric Association (APA) announced on Saturday the changes to its flagship manual that doctors use to diagnose patients with mental disorders. It's the first major rewriter to the DSM in nearly 20 years. 
 
 The familiar "Asperger's," along with some similar disorders, will be lumped together under autism spectrum disorder, "to help more accurately and consistently diagnose children with autism," the APA said in a statement. 
 
 Other changes include entries for new disorders such as "hoarding disorder" or "disruptive mood dysregulation disorder (DMDD)," the latter characterized by abnormally bad and frequent temper tantrums. "Dyslexia" and other learning disorders that some feared would be removed from the manual, remained. 
 
 "We developed DSM-5 by utilizing the best experts in the field and extensive reviews of the scientific literature and original research, and we have produced a manual that best represents the current science and will be useful to clinicians and the patients they serve," APA president Dr. Dilip Jeste, said in a written statement. 
 
 Full details of all the revisions will come in May 2013 when the APA's new manual is published, but the impact will be huge, affecting millions of children and adults worldwide. The manual also is important for the insurance industry in deciding what treatment to pay for, and it helps schools decide how to allot special education. 
 
 It "shapes who will receive what treatment," said Dr. Mark Olfson, a Columbia University psychiatry professor who was not involved in the revision process. More important, he said, "Even seemingly subtle changes to the criteria can have substantial effects on patterns of care." 
 
 The aim is not to expand the number of people diagnosed with mental illness, but to ensure that affected children and adults are more accurately diagnosed so they can get the most appropriate treatment, said Dr. David Kupfer, who chaired the task force in charge of revising the manual, and is a psychiatry professor at the University of Pittsburgh. 
 
 Autism: Can it be outgrown? 
 
 Study links flu with autism risk 
 
 Autism-spectrum disorders: 24 warning signs 
 
 One of the most hotly argued topics ahead of the revisions was how to define the various ranges of autism. Some advocates opposed the idea of dropping the specific diagnosis for Asperger's. People with that disorder often have high intelligence and vast knowledge on narrow subjects but lack social skills. 
 
 Some who have the condition embrace their quirkiness and vow to continue to use the label. And some Asperger's families opposed any change, fearing their kids would lose a diagnosis and no longer be eligible for special services. 
 
 Lori Sherry, president of the Asperger Syndrome Education Network, told the New York Times in March, "Our fear is that we are going to take a big step backward. If clinicians say, 'These kids don't fit the criteria for an autism spectrum diagnosis,' they are not going to get the supports and services they need, and they're going to experience failure." 
 
 
 
 But the revision will not affect their education services, experts say. 
 
 The new manual adds the term "autism spectrum disorder," which already is used by many experts in the field. Asperger's will be dropped and incorporated under that umbrella diagnosis, which will also include kids with severe autism, who often don't talk or interact, as well as those with milder forms. 
 
 Kelli Gibson of Battle Creek, Mich., who has four sons with various forms of autism, said Saturday she welcomes the change. Her boys all had different labels in the old diagnostic manual, including a 14-year-old with Asperger's. 
 
 "To give it separate names never made sense to me," Gibson said. "To me, my children all had autism." 
 
 Three of her boys receive special education services in public school; the fourth is enrolled in a school for disabled children. The new autism diagnosis won't affect those services, said Gibson, who also has a 3-year-old daughter without autism. 
 
 People with dyslexia also were closely watching for the new updated doctors' guide. Many with the reading disorder did not want their diagnosis to be dropped -- and it won't be. Instead, the new manual will have a broader learning disorder category to cover several conditions including dyslexia, which causes difficulty understanding letters and recognizing written words. 
 
 The trustees on Saturday made the final decision on what proposals made the cut; recommendations came from experts in several work groups assigned to evaluate different mental illnesses. 
 
 The revised guidebook "represents a significant step forward for the field. It will improve our ability to accurately diagnose psychiatric disorders," Dr. David Fassler, the group's treasurer and a University of Vermont psychiatry professor, said after the vote. 
 
 Group leaders said specifics won't be disclosed until the manual is published but they confirmed some changes. A 2000 edition of the manual made minor changes but the last major edition was published in 1994. 
 
 Olfson said the manual "seeks to capture the current state of knowledge of psychiatric disorders. Since 2000 ... there have been important advances in our understanding of the nature of psychiatric disorders." 
 
 Dr. Catherine Lord, an autism expert at Weill Cornell Medical College in New York who was on the psychiatric group's autism task force, said anyone who met criteria for Asperger's in the old manual would be included in the new diagnosis. 
 
 One reason for the change is that some states and school systems don't provide services for children and adults with Asperger's, or provide fewer services than those given an autism diagnosis, she said. 
 
 Autism researcher Dr. Geraldine Dawson, chief science officer for the advocacy group Autism Speaks, expressed "cautious optimism" at the revisions. She said small studies have suggested the new criteria will be effective. But she said it will be crucial to monitor so that children don't lose services, a major concern of the organization that it has discussed with the committee during the revision process. 
 
 "We are reassured that the DSM-5 committee has stated that all individuals who currently have a diagnosis on the autism spectrum, including those with Asperger syndrome, will be able to retain an ASD diagnosis," Dawson wrote on Autism Speaks' website. "This means that no one with a current diagnosis on the autism spectrum should "lose" their diagnosis because of the changes in diagnostic criteria." 
 
 Other changes to the manual include: 
 
 *Hoarding disorder will be added to the DSM-5 to help characterize people who can't part with possessions, regardless of their actual value. The APA says the disorder usually has emotional, physical, social, financial and even legal effects for a hoarder and family members. 
 
 *A new diagnosis called disruptive mood dysregulation disorder, or DMDD, for children with recurrent temper tantrums. Critics say it will medicalize kids' who have normal tantrums while supporters argue it will address concerns about too many kids being misdiagnosed with bipolar disorder and treated with powerful psychiatric drugs. Bipolar disorder involves sharp mood swings and affected children are sometimes very irritable or have explosive tantrums. 
 
 *A new obsessive-compulsive and related disorder called excoriation, or skin-picking, disorder. 
 
 *Removing a bereavement exclusion from depression criteria that previously applied to people who experienced symptoms lasting less than two months following the death of a loved one. The APA now says bereavement is a severe psychosocial stressor that can trigger major depression soon after the death of a loved one. 
 
 *Eliminating the term "gender identity disorder," which has been used for children or adults who strongly believe that they were born the wrong gender. But many activists believe the condition isn't a disorder and say calling it one is stigmatizing. The term would be replaced with "gender dysphoria," which means emotional distress over one's gender. Supporters equated the change with removing homosexuality as a mental illness in the diagnostic manual, which happened decades ago. ||||| The DSM-5 was officially released today. We will be covering it in the weeks to come here on the blog and over at Psych Central Professional in a series of upcoming articles detailing the major changes. 
 
 In the meantime, here is an overview of the big changes. We sat in on a conference call that the American Psychiatric Association (APA) had in order to introduce the new version of the diagnostic reference manual used primarily by clinicians in the U.S. to diagnose mental disorders. It is called the Diagnostic and Statistical Manual of Mental Disorders and is now in its fifth major revision (DSM-5). 
 
 James Scully, Jr., MD, CEO of the APA, kicked off the call by remarking that the DSM-5 will be a “critical guidebook for clinicians” — a theme echoed by the other speakers on the call. 
 
 Why has it taken on such a large “role [both] in society as well as medicine?” he asked. Dr. Scully believes it’s because of the prevalence of mental disorders in general, touching most people’s lives (or someone we know). 
 
 The APA has published three separate drafts of the manual on their website, and in doing so received over 13,000 comments from 2010 – 2012, as well as thousands of emails and letters. Every single comment was read and evaluated. This was an unprecedented scale of openness and transparency never before seen in the revision of a diagnostic manual. 
 
 “The manual is first and foremost a guidebook for clinicians,” reiterated David Kupfer, M.D., DSM-5 task force chair, who walked us through the major changes detailed below. 
 
 1. Three major sections of the DSM-5 
 
 I. Introduction and clear information on how to use the DSM. 
 
 II. Provides information and categorical diagnoses. 
 
 III. Section III provides self-assessment tools, as well as categories that require more research. 
 
 2. Section II – Disorders 
 
 Organization of chapters is designed to demonstrate how disorders are related to one another. 
 
 Throughout the entire manual, disorders are framed in age, gender, developmental characteristics. 
 
 Multi-axial system has been eliminated. “Removes artificial distinctions” between medical and mental disorders. 
 
 DSM-5 has approximately the same number of conditions as DSM-IV. 
 
 3. The Big Changes in Specific Disorders 
 
 Autism 
 
 There is now a single condition called autism spectrum disorder, which incorporates 4 previous separate disorders. As the APA states: 
 
 ASD now encompasses the previous DSM-IV autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. ASD is characterized by 1) deficits in social communication and social interaction and 2) restricted repetitive behaviors, interests, and activities (RRBs). Because both components are required for diagnosis of ASD, social communication disorder is diagnosed if no RRBs are present. 
 
 Disruptive Mood Dysregulation Disorder 
 
 Childhood bipolar disorder has a new name — “intended to address issues of over-diagnosis and over-treatment of bipolar disorder in children.” This can be diagnosed in children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behavioral dyscontrol (e.g., they are out of control). 
 
 ADHD 
 
 Attention deficit hyperactivity disorder (ADHD) has been modified somewhat, especially to emphasize that this disorder can continue into adulthood. The one “big” change (if you can call it that) is that you can be diagnosed with ADHD as an adult if you meet one less symptom than if you are a child. 
 
 While that weakens the criteria marginally for adults, the criteria are also strengthened at the same time. For instance, the cross-situational requirement has been strengthened to “several” symptoms in each setting (you can’t be diagnosed with ADHD if it only happens in one setting, such as at work). 
 
 The criteria were also relaxed a bit as the symptoms now have to had appeared before age 12, instead of before age 7. 
 
 Bereavement Exclusion Removal 
 
 In the DSM-IV, if you were grieving the loss of a loved one, technically you couldn’t be diagnosed with major depression disorder in the first 2 months of your grief. (I’m not sure where this arbitrary 2 month figure came from, because it certainly reflects no reality or research.). This exclusion was removed in the DSM-5. Here are the reasons they gave: 
 
 The first is to remove the implication that bereavement typically lasts only 2 months when both physicians and grief counselors recognize that the duration is more commonly 1–2 years. Second, bereavement is recognized as a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual, generally beginning soon after the loss. When major depressive disorder occurs in the context of bereavement, it adds an additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer somatic health, worse interpersonal and work functioning, and an increased risk for persistent complex bereavement disorder, which is now described with explicit criteria in Conditions for Further Study in DSM-5 Section III. Third, bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes. It is genetically influenced and is associated with similar personality characteristics, patterns of comorbidity, and risks of chronicity and/or recurrence as non–bereavement-related major depressive episodes. Finally, the depressive symptoms associated with bereavement-related depression respond to the same psychosocial and medication treatments as non–bereavement-related depression. In the criteria for major depressive disorder, a detailed footnote has replaced the more simplistic DSM-IV exclusion to aid clinicians in making the critical distinction between the symptoms characteristic of bereavement and those of a major depressive episode. 
 
 PTSD 
 
 More attention is now paid to behavioral symptoms that accompany PTSD in the DSM-5. It now includes four primary major symptom clusters: 
 
 Reexperiencing 
 
 Arousal 
 
 Avoidance 
 
 Persistent negative alterations in cognitions and mood 
 
 “Posttraumatic stress disorder is now developmentally sensitive in that diagnostic thresholds have been lowered for children and adolescents. Furthermore, separate criteria have been added for children age 6 years or younger with this disorder.” 
 
 Major and Mild Neurocognitive Disorder 
 
 Major Neurocognitive Disorder now subsumes dementia and the amenstic disorder. 
 
 But a new disorder, Mild Neurocognitive Disorder, was also added. “There was concern we may have added a disorder that wasn’t ‘important’ enough.” 
 
 “The impact of the decline was noticeable, but clinicians lacked a diagnosis to give patients,” noted Dr. Kupfer. There were two reasons for this change: “(1) Opportunity for early detection. The earlier the better for patients with these symptoms. (2) It also encourages an early effective treatment plan, ” before dementia sets in. 
 
 Other New & Notable Disorders 
 
 Both binge eating disorder and premenstrual dysphoric disorder and now official, “real” diagnoses in the DSM-5 (they were not prior to this, although still commonly diagnosed by clinicians). Hoarding disorder is also now recognized as a real disorder, separate from OCD, “which reflects persistent difficulty dis-carding or parting with possessions due to a perceived need to save the items and distress associated with discarding them. Hoarding disorder may have unique neurobiological correlates, is associated with significant impairment, and may respond to clinical intervention.” 
 
 Jeffrey Lieberman, MD, President-Elect of the APA reminded us that the DSM-5 is not a pop-psychology book intended for consumers: “[It is] a guide, an aide to assist clinicians to … help facilitate treatment.” 
 
 The APA also noted that a large number of sessions — 21 — will be dedicated to the DSM-5 this weekend at the APA’s annual meeting. 
 
 Commenting on the swirling controversy regarding the DSM-5, that perhaps the diagnostic system isn’t good enough, Dr. Lieberman said, “It can’t create the knowledge, it reflects the current state of our knowledge.” 
 
 “We can’t keep waiting for such breakthroughs,” (in reference to biomarkers and laboratory tests). “Clinicians and patients need the DSM-5 now. 
 
 Critics have accused the DSM-5 of lowering diagnostic thresholds across the board, making it far easier for a person to be diagnosed with a mental disorder. Lieberman disagrees, however: “How [the DSM-5] is applied reflects critical practice… it’s not necessarily because of the criteria [themselves]. It’s because of the way the criteria are applied.” 
 
 Want to learn more about the 
 
 specific changes in the DSM-5? 
 
 Stay updated by visiting our DSM-5 Resource Guide.
– A new edition of the manual doctors use to diagnose mental illness, the DSM, has just been released by the American Psychiatric Association—but it has already been stirring up controversy for months, reports CBS. Most critically, the director of the National Institute of Mental Health has spoken out against DSM-5, saying its definitions are too broad and lack scientific validity, the New York Times reports. "As long as the research community takes the DSM to be a bible, we’ll never make progress," he said. "People think that everything has to match DSM criteria, but you know what? Biology never read that book." Among other changes, the new DSM-5 has encompassed four previously separate disorders under the blanket "autism spectrum disorder." Another change: previously, those grieving for a lost love one couldn't be diagnosed with depression within two months of the death. Now bereavement is actually classed as a trigger. (PsychCentral has a thorough rundown of all the changes.) John Hopkins psychiatry professor Paul McHugh has also criticized the new manual in the Washington Post, saying it encourages doctors to rely on check-lists rather than getting to know their patients. "DSM-5 will be more of the same—a way to 'know of' disorders without 'knowing about' them," he writes.