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American Psychiatric Publishing

 By Dr. Lawana R. Lofton

The American Psychiatric Association (APA) extensive revision to the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition  (DSM-5), is nearing its conclusion.   Reportedly, December 1, 2012, the  American Psychiatric Association (APA) announced an end to its 13-year process of revising the DSM-5.   Publication is expected  in May 2013.

According to the American Psychiatric Association (APA) website,  the last stage of the manual’s development began late June 2012 at the end of a six-week open-comment period for health professionals, patients and families, advocates and others.

On this date, the website had removed what specific criteria will be impacted by the revisions citing the manual is still undergoing revisions and they elected to remove “final drafts” to avoid confusion.   Plus, there are more rounds of allowed comments and voting which may impact the ultimate final publishing manual.

DSM-5  will have impact on all who receive Mental Health Services directly, those who provide services to patients such as Psychologist, Psychiatrist, Therapists, along with Behavioral Health Researchers, and Insurance Companies.  

As background, in the world-wide  Mental Health Community, we have two dominate reference documents for the primary use of assigning a Mental Health Diagnosis.   One, the Diagnostic Statistical Manual (DSM)  published by the American Psychiatric Association (APA),   and two, the European International Statistical Classification of Diseases (ICD) and Related Health Problems, produced by the World Health Organization.   Both are largely aligned, yet  there are small differences in wording, and some definitions  that  do lead to quite different prevalence rates among disorders.

Financially, from Alaska to Australia and every State and Territory in between that uses an English Psychiatric DSM for assigning Mental Health Diagnosis will need to purchase a new APA Manual to stay current.  Every clinician in practice, library who shelves a DSM-IV-TR will need to update their library, every University and Educational institution, every professional facility and  local outpatient clinic.  Publishing Market revenue widens also to all State Hospitals, Research Facilities, Inpatient Facilities, Insurance Company Peer Reviewers, and Prisons with Mental Health Staff onboard who as part of their position,  must evaluate or assign accurate diagnosis for treatment  recommendations.  

Listed below are a few of the tentative changes proposed as summarized By John Cloud, Senior Writer at Time Magazine,  on December 3, 2012. 

1.   Autistic Disorder  will become  Autism Spectrum Disorder.

This  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 NOS.  Combining Autism and Asperger’s is especially controversial partly because Autism can be so much more serious than Asperger’s.   Although some Autistic individuals can function extremely well,  others affected by the disorder need lifelong care for basic needs.   

The change will likely cause considerable debate because the diagnosis assigned will impact access and eligibility to educational and social services needed to manage the disorder.  

2.   Binge-Eating Disorder will be moved from DSM‘s Appendix B, a category of proposed conditions that require “further study,” to an  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.   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 “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 Psychologists, Psychiatrists,  Therapists, will be able to diagnose Depressive Disorder,  even among those who have  lost a loved one.   And assign a diagnosis code for treatment which would allow for insurance reimbursement.  Bereavement has always been a V-Code which means a person is suffering a PsychoSocial  presenting problem, but not severe enough to warrant medical necessity to use insurance to pay for clinical Mental Health Treatment.

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.  The APA reports the new diagnosis  “is intended to address concerns about potential over-diagnosis and over-treatment of Bipolar Disorder in children.”

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).   Hoarding was previously considered a form of Obsessive Compulsive Disorder.

What will not be added to the DSM is Hypersexual Disorder; a 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 money-maker 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,  John Cloud also included in his summary of revisions.

Above and beyond 13-years of conversations regarding changes, we are simply at the end of what appeared long negotiations to either update, include, or exclude  certain categories of symptoms and behaviors.  Stay Tuned!  It may be too early to speculate if rather the “early drafts” will include substantive changes, or is merely a way to generate new publishing revenue.

Until Next Time:  a’Donf