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Revised psychiatry manual targets autism, substance disorders

Posted Feb 11 2010 5:57am


People with Asperger's syndrome would be included in the same diagnostic group as people with autism and pervasive developmental disordersaccording to new guidelines under consideration by the American Psychiatric Association.

Psychiatrists are in the process of revising the guidelinesknown as the Diagnostic and Statistical Manual of Mental Disorders. The manual has implications for how psychiatric drugs are developed and prescribedwhat treatments get covered under insurance planswhich approach doctors take in treating their patientsand how patients view their own identities.

Anyone who has received a diagnosis from a mental health professional has most likely had his or her symptoms defined by the guidebook.

The revisionswhich will be in the DSM's fifth editiondue in 2013were made public Wednesday at DSM5.org.

The proposal for a single category for autism that encompasses a broad range of conditions is generating debate.

Scientificallythe distinction is correct; the research on people with these conditions has shown that Asperger's is on the mild end of the spectrum of autistic disorderssaid Dr. Michael Firstprofessor of clinical psychiatry at Columbia Universitywho worked on the version of the DSM that is currently in use.

Of concern is that Asperger's has been destigmatized and autism has nothe said. Over the past 15 yearscommunities have formed around Asperger'sand the condition has taken on more positive tones with the notions that Albert Einstein and other intellectual luminaries may have had it.

Given that Asperger's has become more acceptableFirst favors keeping it as a diagnosis.

"This is a case where the science of the decision and social ramifications of the decision are separate," First said.

But the DSM does not make diagnoses based on the stigma of one group over anothersaid Catherine Lorddirector of the University of Michigan Autism and Communication Disorders Centerwho is on the American Psychiatric Association committee looking at autism.

"Many people prefer to use the term Asperger'sand we're not saying that you can't describe yourself that way," she said. But the research shows "no scientific evidence that there are separate syndromes."

The term Asperger's has become too vague and may currently prevent some children from receiving the assistance they need at schools that offer "autism" services and don't necessarily include themLord said.

The new criteria require that the symptoms begin in early childhood and that deficits be measured in two areas: social interaction and communicationand the presence of repetitive behaviors and fixated interests and behaviors.

First also takes issue with "psychosis risk syndrome," a proposed classification of the set of symptoms that sometimes precede schizophrenia.

For examplemilder versions of delusionsdisorganized speech and hallucinations fall under this. In First's analysishoweveronly 20 percent of people with this set of early symptoms would go on to develop schizophrenia.

That means "an unusual and unconventional adolescent who has a very rambling writing and speaking stylewhose parents are concerned about the fact that their son is differentcould qualify for this disorder," he said.

This kind of diagnosis could ruin this person's lifeaffecting his social life and college plansand landing him on antipsychotic medications with strong side effects.

But Dr. Charles Raisonpsychiatrist at Emory Universitysaid there is some evidence that looking for psychosis early has tremendous benefits.

The psychiatric association's rationale for considering psychosis risk syndrome is that psychotic illness is most effectively treated early and that intervening early may have long-lasting benefits not achievable with later therapythe proposal said. But moving forward on putting this on the list of disordersor in the appendixdepends on field trials.

First and Raison both lauded the association for proposing to get rid of the terms "substance abuse" and "substance dependence" and putting them under one name: addiction and related disorderswith the subheading "substance use disorders."

Problems with thinking and memoryknown as neurocognitive disordershave been divided into "major" and "minor," said Dr. Dan Blazerprofessor of psychiatry at Duke University School of Medicine. In the pastpeople with "minor" impairments -- for exampleminor dementia -- may not have been covered by insuranceand reframing the conditions in this way would include themhe said.

"Many people come seeking help because they are having some difficulty with their cognition but don't qualify for a diagnosis currently," said Blazerwho was part of the committee to revise the neurocognitive disorder criteria. "These are people that clearly need to be seenand there's a very good reason for them to be seen."

At the same timepsychiatrists have recommended getting away from the word "dementia" because it has "outgrown its time," Blazer said. Dementia does not accurately describe what's going on in a person with cognitive impairmenthe said.

The term will probably not disappear completely. For instanceit has not been decided whether "vascular dementia" ought to be renamedhe said.

Taking "dementia" out will probably not cause the same degree of controversy as decisions regarding autism classification because the proposed changes simply clarify what "dementia" actually meanshe said.

Firsthoweveris skeptical of this move.

"It feels to me like they're fixing a problem that wasn't there," he said. "No one has ever said to me'There's a problem with the word "dementia." ' "

Blazer's group also proposed using biological markers as guides for diagnosis. For exampleseveral studies are ongoing to identify the signatures of Alzheimer's disease in brain scans. No such tests are currently required by the DSMbut the revisions note that they are useful in ruling in or out certain conditions.

"We are moving toward trying to include some kind of more quantitative assessment of the severity of the conditionwhich will help us in this major-minor distinction," Blazer said.

The proposed revisions also include new classifications for learning disorders. The new category "learning disabilities" will have the subcategories of dyslexiarelated to readingand dyscalculiarelated to mathematics. This is a further specification of what academic skills should inform a diagnosisLord said.

The committees do not take insurance or drug company opportunities into account when crafting revisions to the DSMshe said. But First noted that the DSM does have these implications.

"Any new disorder added provides an opportunity for a pharmaceutical company to develop a new drug," First said.

But Raison said the era of trying to treat an entire diagnosis is overmeaning the DSM V may have less of an impact than its predecessors in generating new drugs. As psychiatrists realize that mental illness diagnoses are sometimes vague descriptions rather than biological entitiesthere is a movement toward treating individual symptomshe said.

"We're in a bit of a backlash right nowand I think the golden age of just taking these psychiatric diagnoses as if they're real things that exist in natureI think those days have been winding down," he said.

The new criteria will be available for public comment at DSM5.org until April 20. They will reviewed and refined over the next two yearsduring which time the American Psychiatric Association will conduct field trials to test some of the proposed revisions in real-world clinical settings.

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