Since it was first published in 1952, the DSM has been the has been the diagnostic bible for many psychiatrists. Each time the manual is updated, new conditions are introduced, often amid much controversy. DSM-5, the latest edition published on Saturday, is one of the most controversial yet.
Many conditions we’re now familiar with were codified in the DSM, including body dismorphic disorder, schizophrenia and bipolar disorder.
Inclusions and removals can be hugely controversial. Autism is in the manual, for example, but Asperger’s isn’t. Homosexuality was only removed in 1974.
Below, five experts explain some of the most noteworthy new additions, and why they’ve been included.
David Mataix-Cols: Most children have collections at some point and approximately 30% of British adults define themselves as collectors. This is a pleasurable, highly social and benign activity, which contrasts with another disabling form of object accumulation: hoarding disorder.
The symptoms include persistent difficulty in discarding possessions due to a strong perceived need to save items and distress in discarding them. This results in the accumulation of a large number of possessions that fill up and clutter key living areas of the home, to the extent that their intended use is no longer possible.
Symptoms are often accompanied by excessive acquiring, buying or even stealing of items that are not needed or for which there is no available space.
Using DSM-5, hoarding disorder can only be diagnosed once other mental disorders have been ruled out.
With a prevalence of at least 1.5% of the UK population, the disorder is associated with substantial functional disability, family conflict, social isolation, risk of falls and fires, evictions and homelessness.
Binge eating disorder
Christopher Fairburn: The inclusion of binge eating disorder in the DSM-5 was expected and uncontroversial for the deciding committee. It’s already listed as a provisional diagnosis in the DSM-4.
The disorder is characterised by recurrent over-eating episodes and a sense of loss of control at the time. Sufferers don’t have the extreme dieting, vomiting and laxative misuse seen in people who have bulimia. It is the loss of control over eating that is the distressing feature of binge eating disorder, or BED.
BED is very different from anorexia nervosa and bulimia nervosa. These disorders are largely confined to young women and they share many features including highly distinctive concerns about shape and weight and extreme weight control behaviour, such as dieting. None of this is present in people with BED.
BED is typically seen among those who are middle aged. Men make up about a third of cases. The disorders also differ in their response to treatment. Unlike anorexia and bulimia, people who suffer from binge eating disorder respond well to a variety of treatments.
Skin picking disorder
Jon Grant: Skin picking has been documented in medical literature since the 19th century but only now has it been recognised in the DSM-5.
Skin picking disorder affects around 2-5% of people in the US. It is not simply a harmless habit nor merely a symptom of another disorder. Skin picking may result in significant tissue damage and often leads to medical complications such as local infections and septicemia.
Sufferers of the disorder are diagnosed according to five criteria including recurrent skin picking that causes skin lesions; repeated attempts to cut down or stop, and that the skin picking causes significant distress or problems in social situations, work, or other important areas in life.
Skin picking also can’t exist due to the physical effects of a substance or a medical condition, or be linked to another mental disorder - for example because someone has body dysmorphic disorder. These criteria separate people who only pick their skin occasionally.
Data from multiple researchers around the world consistently show that skin-picking disorder has distinct characteristics, important neurobiological links, and documented responsiveness to treatments - both Cognitive Behaviour Therapy and medication can work.
Somatic symptom disorder
Christopher Lane: Somatic comes from the Greek word for “of the body”, the focus of the disorder. DSM’s earlier family of medically unexplained ailments grouped together problems as different as hypochondria and body dysmorphia and so the American Psychiatric Association proposed somatic symptom disorder.
It’s a new, stand-alone disorder for people who experience a “disproportionate” sense of anxiety about their health and at least one physical symptom, such as a persistent headache.
People can be diagnosed with the new disorder if their physical symptoms are distressing and/or disruptive to their daily life for at least six months, and they also have one of the following: disproportionate thoughts about the seriousness of their symptoms; or a high level of anxiety about their symptoms or health; or they devote excessive time and energy to their symptoms or health concerns.
There have been concerns because the threshold of “disproportionate” and “excessive” is difficult to quantify and the disorder could be used as a catch-all for many people.
Karen M. von Deneen, Jie Tian: While not yet officially codified within a psychopathological framework, internet addiction is growing in prevalence and has attracted the attention of psychiatrists, educators, and the public.
Internet addiction is a newly identified condition associated with loss of control over internet use. It leads to negative psychosocial and physical results, such as impairment of academic failure, social deficits, criminal activities and even death. This consists of three main subtypes: excessive gaming, sexual preoccupations, and e-mail/text messaging.
The DSM-5 now includes a newly-created category of behavioural addictions, in which gambling will be the sole disorder. Internet addiction was considered for this category, but work group members decided there was insufficient research data to do so, so they recommended it be included in the manual’s appendix instead, with the goal of encouraging additional study.
Present treatment has included electric shock therapy and internet rehab, but these have not been satisfactory. More research needs to be done to understand the underlying mechanisms of this addiction.