text: 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. ||||| The creators of the D.S.M. in the 1960s and ’70s “were real heroes at the time,” said Dr. Steven E. Hyman, a psychiatrist and neuroscientist at the Broad Institute and a former director at the National Institute of Mental Health. “They chose a model in which all psychiatric illnesses were represented as categories discontinuous with ‘normal.’ But this is totally wrong in a way they couldn’t have imagined. So in fact what they produced was an absolute scientific nightmare. Many people who get one diagnosis get five diagnoses, but they don’t have five diseases — they have one underlying condition.” 
   
   Dr. Hyman, Dr. Insel and other experts said they hoped that the science of psychiatry would follow the direction of cancer research, which is moving from classifying tumors by where they occur in the body to characterizing them by their genetic and molecular signatures. 
   
   About two years ago, to spur a move in that direction, Dr. Insel started a federal project called Research Domain Criteria, or RDoC, which he highlighted in a blog post last week. Dr. Insel said in the blog that the National Institute of Mental Health would be “reorienting its research away from D.S.M. categories” because “patients with mental disorders deserve better.” His commentary has created ripples throughout the mental health community. 
   
   Dr. Insel said in the interview that his motivation was not to disparage the D.S.M. as a clinical tool, but to encourage researchers and especially outside reviewers who screen proposals for financing from his agency to disregard its categories and investigate the biological underpinnings of disorders instead. He said he had heard from scientists whose proposals to study processes common to depression, schizophrenia and psychosis were rejected by grant reviewers because they cut across D.S.M. disease categories. 
   
   “They didn’t get it,” Dr. Insel said of the reviewers. “What we’re trying to do with RDoC is say actually this is a fresh way to think about it.” He added that he hoped researchers would also participate in projects funded through the Obama administration’s new brain initiative. 
   
   Dr. Michael First, a psychiatry professor at Columbia who edited the last edition of the manual, said, “RDoC is clearly the way of the future,” although it would take years to get results that could apply to patients. In the meantime, he said, “RDoC can’t do what the D.S.M. does. The D.S.M. is what clinicians use. Patients will always come into offices with symptoms.” 
   
   For at least a decade, Dr. First and others said, patients will continue to be diagnosed with D.S.M. categories as a guide, and insurance companies will reimburse with such diagnoses in mind. ||||| 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. ||||| Psychiatry tops all other disciplines of medicine in captivating and confusing the public. It captivates because of the storied disturbances in human thought, emotion and behavior that psychiatrists describe. It confuses because, to the natural question, "What exactly are these disturbances?" psychiatrists today just provide a list of diagnoses, as if naming disorders explains them. 
   
   Ellen Weinstein The most enduring feature of Freudianism was its claim that important facts about a patient's mental life are buried in the "unconscious." 
   
   Jerome Groopman, in his informative 2007 book "How Doctors Think," confesses that "trying to assess how psychiatrists think was beyond my abilities." If this gifted physician finds psychiatry mystifying, how can we expect ordinary people who are seeking help to form suitable judgments? 
   
   Things will not improve with the American Psychiatric Association's release this week of the fifth edition of its famed Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Like its predecessors, the massive new volume will shape what psychiatrists say and do with their patients. It is thus a perfect moment to consider how the DSM came about in the first place—and why this new edition will do nothing to clear up the public's growing confusion. 
   
   From about 1940 to 1970, Sigmund Freud's theoretical concepts of mental life and its disorders dominated American psychiatry. The most enduring, problematic feature of Freudianism was its claim that the important facts about our mental life are disguised, buried in the "unconscious," stifled by convention and conformity. 
   
   Only a Freudian analyst instructed in the supposedly universal conflicts of human sexuality and domestic life (the Oedipal complex, etc.) could decode and disentangle them. By knowing these secrets, the analyst could derive—from the disguises "manifest" in dreams, slips of the tongue, symptoms and behaviors—the "latent" truth provoking the different mental disorders. 
   
   Freud and his followers played down efforts at gathering such information as a patient's family background, educational and occupational course, intelligence, temperament, habits, medical condition and conscious assumptions. These factors were said to lack psychological depth. 
   
   In the 1960s, the authority of the Freudians began to wane in America, partly because their ineffectiveness with serious mental disorders became evident and partly because their treatments were costly, in both time and money. At the same time, the field began to make real progress with the discovery of medications, such as lithium, that were effective against specific and severe mental disorders. New psychological treatments such as Cognitive Behavioral Therapy also emerged and helped patients by addressing their conscious attitudes rather than conjectures about their unconscious minds. 
   
   Still, among many psychiatrists, the notion persisted that the true causes of mental disorders were unconscious. This belief opened the doors of psychiatry in the 1970s to many wild and conflicting suppositions about mental illnesses. Psychiatrists began acting like Sherlock Holmes, looking for various "dogs that didn't bark" to explain their patients' problems. This brought us fiascoes such as the multiple-personality craze and "repressed memories" of child abuse. Grotesque therapeutic programs—"encounter groups," the use of hallucinogenic drugs such as LSD, primal-scream therapy—also found their day, in the name of bringing "the hidden" to consciousness for treatment. 
   
   Ultimately, the profession could not tolerate the mounting turmoil. In 1980, the APA proposed simply setting aside the chaos of claims about the causes and mechanisms of mental disorders, including those of the Freudians. Were there not aspects of mental illnesses that everyone in the profession could recognize and agree upon? 
   
   With its third edition (DSM-III), the manual (which had existed since 1952) underwent a transformation. Its editors focused on codifying symptoms that seemed to distinguish one mental disorder from another. If psychiatrists would use these criteria consistently, they suggested, then perhaps researchers would be able to explain and differentiate disorders in terms of psychobiology. 
   
   This prescription for diagnostic peacemaking radically changed the psychiatric scene. No longer was it an unruly market of claims, counterclaims and "orientations." Psychiatric practices became centered on using the manual to identify disorders, much as a naturalist uses a field guide to identify birds or trees. The treatments derived from these diagnoses had no particular theory behind them. They were efforts, mostly pharmacological and rule-of-thumb, to provide relief from symptoms. Psychiatric thinking about patients and their disorders withered. 
   
   Today the public complains that psychiatrists seem ready to call every state of mental distress an illness. They see that any restless boy can receive a diagnosis of attention deficit disorder, that troubled veterans—whether exposed to combat or not—are routinely said to suffer from post-traumatic stress disorder, and that enormous numbers of discouraged, demoralized people are labeled victims of depression and have medications pressed upon them. 
   
   The public is not far wrong. A recent nationwide diagnostic census based on DSM claimed that the majority of Americans have or have had a mental disorder. As a result, an appalling number of young adults in schools and colleges are on one form or another of psychiatric medication. 
   
   The problem, though, is not only that psychiatrists have gone too far in naming mental states—they surely have—but that they have gone on too long with their field-guide checklists. They seem unable to do better. DSM-5 will be more of the same—a way to "know of" disorders without "knowing about" them, to draw a distinction made by William James. 
   
   With its new manual, the APA might instead have started taking steps toward a system of classification that, as in medicine, organizes disorders according to what we know about their natures and causes. Such knowledge, rather than checklists of symptoms, would then direct treatment and research. 
   
   Psychiatrists know, for instance, that depression and anxiety can derive from a number of different sources: cerebral diseases such as schizophrenia and bipolar disorder; alcoholism or drug addiction; experiences of loss, deprivation or trauma; and, more generally, a vulnerable temperament, characterized by introversion, shyness and emotional intensity. 
   
   Deciding which of these sources, alone or in combination, applies to a particular patient requires hours of evaluation. Prescribing an appropriate treatment involves not checking symptoms but determining who the patient is and what he or she has experienced and done. 
   
   DSM-5 displays none of this thinking. It remains a field guide organized by symptoms, clustered in categories that can expand without limit. Official, APA-approved psychiatry seems to lack the will to change. It justifies its stagnation not only by reminding its members of the chaos of the 1970s but by claiming that the U.S. health system would not pay psychiatrists if they tried to know their patients the way that they could and should. 
   
   DSM-5 is a missed opportunity to advance the discipline, instruct the public and encourage financial support for needed psychiatric services. Its editors seem willing to waste another decade before dispersing the mysteries of psychiatry and bringing practitioners and patients together in understanding what they are doing and why. 
   
   —Dr. McHugh is University Distinguished Professor of Psychiatry at Johns Hopkins and former psychiatrist in chief at Johns Hopkins Hospital. 
   
   A version of this article appeared May 18, 2013, on page C3 in the U.S. edition of The Wall Street Journal, with the headline: A Manual Run Amok.
target: – 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.