DSM-5 Diagnostic Changes Gambling - Sex

I have been discussing some proposed changes in psychiatric disorder classifications for the fifth edition of The Diagnostic and Statistical Manual of Mental Disoders (DSM-5) which were recently released in draft version by the American Psychiatric Association. The final version won't be published until 2013 and there is opportunity for anyone to make comments on the draft at www.dsm5.org until April 20 of this year. I have discussed some proposed changes in substance use diagnoses, now refereed to as Addiction and Related Disorders as well as the changes regarding autism and Asperger's syndrome. There are also proposed changes in terms of pathological gambling and a new term Hypersexual Disorder.

Pathological gambling will now be referred to as Disordered Gambling and is under the classification of Addiction and Related Disorders as the only non-substance related behavioral addiction. Consideration was given to Internet addiction but it was left out due to lack of enough research in the area. The new categorization of disordered gambling as an addiction makes sense as the dopamine reward system is "hijacked" in gambling in the same way as substance related addictions and there has been a great deal of research in this area. Those in the recovery field have long treated disordered gambling as an addiction and it is good to see some "official" support for the concept.

There was hedging in the area of compulsive like sexual problems. These are not subsumed under the addiction category but are included as a new sexual disorder category, Hypersexual Disorder.The nearest diagnostic neighbors are the paraphilic disorders which are characterized by socially anomalous or deviant sexual arousal such as exhibitionism, fetishes, and pedophilia. The new category referred to as Hypersexual Disorder refers to "normal" sexual behaviors that are repetitive, excessive, or disinhibited. The classification of such issues as a psychiatric disorders will certainly be controversial as there are significant gaps in the current scientific knowledge base regarding antecedent, concurrent, and predictive validators as well as the lack of knowledge regarding developmental risk factors, family history,cognitive markers and neurobiological substrates.In addition there is almost no knowledge regarding these issues in women. There is also no knowledge in our understanding of how excessive sexual behaviors may part of overall impulsivity and inability to delay gratification.

On Medscape, which is an Internet medical site providing medical news, continuing medical education, and physician discussion boards I was amazed by the volume of responses and the vehemence of the responders to the question of whether or not sexual behaviors could be classified as addiction. I haven't seen any other question generate more comments and more heated discussion. I am very interested to see the public comments on Hypersexual Disorder in DSM-5. I will be off blog for several days but when I return I will talk a bit on the diagnostic criteria for this disorder.

Thought for the day

May I show the same compassion for myself that I show to others.

DSM-5 Diagnostic Changes Autism Asperger's

As I mentioned yesterday the draft version of the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) has been released by the American Psychiatric Association. DSM-5 will be the first changes made in diagnostic criteria for psychiatric disorders in 10 years with final publication occurring in 2013 after field trials in real world situations. The draft is available for review at www.dsm5.org with opportunity for public comment until April 20 of this year. There are several proposed diagnostic changes some of which already are controversial. I talked about the substance abuse changes yesterday and today I would like to talk about Autism and Asperger's Disorder.

DSM-5 proposes the elimination of the designation Asperger's Disorder which is to be subsumed by the new category of autistic spectrum disorders with a range of severity. There has already been complaints by those with Asperger's and those who work with patients with this disorder. Asperger's Disorder like autism is characterized by severe sustained impairment in social interaction and development of restricted patterns of behavior, interests, and activities. Unlike autism there are no delays or deviance in language acquisition nor delays in cognitive development and it is not like autism often associated with mental retardation. Characteristically patients with Asperger's appear odd to others. They frequently do not pick up on social cues, their interactions are one sided, focused entirely on their own interests with little empathy or understanding of the other as an individual. They may be intensely focused on one topic, with exclusion of all other interests. But unlike autism the desire for social interaction is present. They just don't know how to do it. Often they are loners, not always because of their own wishes but due to peer's inability to tolerate them.

Some in the field are objecting to placing Asperger's in a category of autistic spectrum disorders because of the potential for increased stigma as well as changes in research funding. I do not know the science behind the proposed change but I can understand how those with no language difficulties cognitive impairment would want to be considered in a somewhat different way than those who have these more severe impairments. I wonder what the ongoing public comments will be on this issue.

Thought for the day

May I show kindness and compassion today.

DSM-5 Diagnostic Changes Substance Abuse

The American Psychiatric Association has released the draft version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This is a work that has been ten years in the making and will replace DSM-IV-TR as the official diagnostic manual for mental health. The DSM-5 is still a work in progress. The draft report has been released to allow for public review and comment before 3 phases of field trials will take place in real world settings before the final version is published in 2013. Anyone can review the document at www.dsm5.org and comment before April 20th. There are a number of proposed revisions which I will discuss here over the next few days but today just want to focus on the proposed changes in substance abuse disorders.

The DSM-5 proposes the elimination of the categories of substance abuse and substance dependence replaced by the category of addictions and related disorders. There will be no differentiation between abuse and dependence. Instead all will be referred to as substance use disorders with varying levels of severity. This has been proposed to try to eliminate the confusion between physiologic dependence upon alcohol or a drug and addiction per se as well as to address the problem with our current categories in which the psychosocial consequences of abuse are given more weight than in the dependence diagnosis itself.

A Substance-Use Disorder will be defined as a clinically significant impairment or distress as manifested by 2 (or more) of the following, occurring within a 12-month period:

Failure to fulfill major role obligations at work, school, or home

Recurrent use of substances in situations in which it is physically hazardous

Continued use despite persistent social and interpersonal problems caused by the
substance

Tolerance - diminished effect with the continued use of the same amount of the substance

Withdrawal syndrome

Taken in larger amounts or over a longer period than was intended

Persistent desire or unsuccessful attempts to cut down on the substance use

A great deal of time spent in activities necessary to obtain the substance

Giving up important occupational or recreational activities

Continued use despite knowledge of having a persistent physical or psychological problem caused or exacerbated by the substance

Craving or a strong desire or urge to use a specific substance

Two to three criteria positive will be referred to as moderate severity with four or more referred to as severe. There will be a separate specifier for with or without physiological dependence.

The proposed changes are also designed to take into account that abuse and dependence are not necessarily two separate categories but represent different severity points on a continuous spectrum of problems. I think these proposed changes represents more the real world than our old categories but will lead to some disagreement about how to define the term alcoholic or addict which are not diagnostic terms per se but are commonly used in the treatment and recovery field. I invite any comments on what you think about these proposed changes.

Thought for the day

Are my actions likely to enhance or detract from an other's well being today?