by Jen Wieczner
May 22, 2013

from MarketWatch Website

Spanish version





Additions to the diagnostic manual include

hoarding and caffeine withdrawal


The release of a new medical text doesn’t normally generate the kind of fever-pitch anticipation of say, a new Harry Potter book or iPhone model.


But the Diagnostic and Statistical Manual of Mental Disorders, or DSM for short, is an exception. The American Psychiatric Association released its revised fifth edition of the manual, which serves as the official authority on mental health diagnoses (and related insurance claims), on Wednesday.


The DSM-5, which informs the way psychiatrists prescribe drugs, comes with 15 new diagnoses - including hoarding and cannabis withdrawal - while eliminating and combining others.

“Sexual aversion disorder,” for example, has been redacted from legitimate diagnoses because of “rare use and lack of supporting research,” according to the APA.

(Until the 1970s, the manual listed homosexuality as a disorder.)


While psychiatrists considered suggestions from medical professionals as well as the public, the updates have already sparked debate and criticism.

“People are just as confused about the question, What is madness?” says Paul McHugh, a professor and former psychiatrist in chief at Johns Hopkins Hospital, who says the DSM-5 fails to distinguish between the underlying causes of the symptoms associated with its diagnoses.


“This is a field guide to the birds.”

But the handbook also sheds light on the current state of the world’s mental health.


The proliferation of medical marijuana has led to a clinical diagnosis of “cannabis withdrawal,” for example. Meanwhile, in a special trial section of the DSM-5 for conditions needing further research, there is now “Internet gaming disorder,” along with suicide-related disorders due to “increased recognition of suicidal ideation.”


Here’s the thinking behind the DSM-5’s 15 new mental disorders.



Social (Pragmatic) Communication Disorder

With this addition to the manual, psychiatrists can now more precisely diagnose speech and written language problems that are unrelated to autism or diminished cognitive ability, according to an American Psychiatric Association fact sheet about the disorder.


Indeed, while symptoms of this disorder, which must date back to childhood, include “inappropriate responses in conversation” and difficulty communicating, the diagnosis can only be made after autism spectrum disorders have been ruled out, according to the APA.


These problems often hamper people’s social lives, academic careers and job performance, and the diagnosis, known as SCD for short, is intended to bring their issues “out of the shadows” and help them get appropriate treatment, according to the fact sheet.

Disruptive Mood Dysregulation Disorder

While this diagnosis, limited to children under 18, could be interpreted by some parents as applicable “anytime you have a temper tantrum,” says McHugh, the tendency to dismiss kids’ outbursts often leads to misdiagnoses, at the expense of the children and their families, when the disorder goes untreated.


The new diagnosis is designed to help families and children who,

“have never been successfully treated for extreme, explosive rages,” says David Kupfer, chairman of the DSM-5 task force and a professor of psychiatry at the University of Pittsburgh.


“Too many severely impaired children like this have fallen through the cracks because they suffer from a disorder that had not yet been defined.”

Premenstrual Dysphoric Disorder

In classifying symptoms preceding women’s monthly cycle as a mental disorder, the DSM-5 has provoked outrage from those who worry that people will use the official illness to discriminate against women, like they have with PMS, the milder sister to PMDD.


(The new disorder was mentioned in an appendix of the DSM-4 as a condition needing further study.)


Other critics worry that the diagnosis could allow people to use common and mundane problems like minor menstrual cramps as medical excuses. But researchers for the DSM-5 found justification for listing the disorder, which affects 2% to 5% of premenopausal women, according to an article published in the American Journal of Psychiatry in May 2012.


Symptoms include depression, “feelings of hopelessness” and bloating sensations at specific times during a woman’s menstrual cycle - severe enough to interfere with people’s ability to function at work or school.

Hoarding Disorder

The television remedy for hoarding on shows such as A&E's “Hoarders” usually involves a heavy-duty house cleaning by a team of professionals and many garbage bags or dumpsters.


But thanks to the DSM-5’s inclusion of “hoarding disorder” as a standalone diagnosis, doctors may be able to treat the condition 'with a pill.'


There is now adequate evidence to confirm the “diagnostic validity” of hoarding, which is characterized by,

“persistent difficulty discarding or parting with possessions due to a perceived need to save the items and distress associated with discarding them,” according to an APA guide to the changes in DSM-5.

The newly added diagnosis is listed under obsessive-compulsive disorders, though the APA admits that there is not enough data to say whether hoarding is truly related to OCD or another mental illness.


Still, hoarding may have underlying neurobiological causes, which may mean that it can be treated with medication.


Indeed, some DSM critics believe the creation of hoarding disorder could be driven by pharmaceutical interests:

“All they are saying is, we think hoarding should be made an illness that we can get paid for,” says McHugh, who believes psychiatrists should investigate the root causes of the hoarding in order to formulate a treatment plan that could involve behavior therapy instead of drugs.

Caffeine Withdrawal

People who are grumpy before they’ve had their morning coffee may welcome caffeine withdrawal to the DSM-5 as a legitimate mental affliction.


A controversial addition, the new diagnosis directly reflects our increasing dependence on caffeine, from the proliferation of Starbucks outlets to the growing array of non-coffee energy drinks and caffeine-injected alcoholic beverages:

“Caffeine is invading our society more and more,” Alan Budney, a psychiatrist who helped develop the DSM-5, said at a 2011 industry symposium, according to reports.

(Caffeine withdrawal was included in an appendix of the DSM-4 as a condition needing further study.)


But some psychiatrists worry that caffeine withdrawal may be an easy way to clinically label symptoms such as headaches, sleep disturbances and moodiness, at the cost of missing a serious pathological disorder.

“The real problem for [psychiatrists] is, 'Will they be able to have time with the patient to distinguish between caffeine withdrawal and the kind of uneasiness and headaches that come from an encounter they might have had in life experiences'?” says McHugh.

Cannabis Withdrawal

Included in the DSM-5 in tandem with caffeine withdrawal, experts say the increasing prevalence of another substance besides coffee merited the new “cannabis withdrawal” diagnosis.


As marijuana has become available to buy legally and for medical purposes in more states, psychiatrists have also noted withdrawal symptoms in people who frequently smoke marijuana and then quit.


A study of 384 lifetime cannabis smokers, conducted in partnership with the National Institutes of Health and published in 2012, found that more than 40% of participants met the withdrawal criteria in the DSM-5.


Only in recent years have medical experts recognized that marijuana can be associated with drug withdrawal, so the DSM until now excluded the condition,

“due to debate about the clinical significance of the cannabis withdrawal syndrome,” according to researchers who helped develop the DSM-5.

But the researchers identified several cannabis withdrawal symptoms that interfered with people’s ability to function normally, including loss of appetite, nightmares and “imagining being stoned (cravings).”

Excoriation (Skin-Picking) Disorder

Under the awning of obsessive-compulsive disorders, this condition is characterized by chronic picking and scratching of the skin that can cause wounds and scabs, and diagnosed when the behaviors are not associated with another disorder.


The disorder can be triggered by other skin irregularities like acne or bug bites, according to a 2011 paper from the University of Cincinnati College of Medicine that proposed including the disorder in the DSM.


The condition can be associated with other disorders involving compulsive eating, buying and stealing, the researchers wrote.


The DSM-5 added,

“excoriation disorder” in light of “strong evidence for its diagnostic validity and clinical utility,” according to the APA, and the problem is often treated with antidepressants, anti-anxiety drugs or other medications.

Binge Eating Disorder

In the context of an increasing national obesity epidemic, psychiatrists made a statement by adding this diagnosis:

“This change is intended to increase awareness of the substantial differences between binge eating disorder and the common phenomenon of overeating,” according to an APA fact sheet.

With nearly 70% of Americans overweight or obese according to the Centers for Disease Control and Prevention, the manual distinguishes between problems with weight versus mental health, noting that,

“while overeating is a challenge for many Americans, recurrent binge eating is much less common, far more severe, and is associated with significant physical and psychological problems.”

(The new disorder was included in an appendix of the DSM-4 as a condition needing further study.)


People with this disorder frequently eat a large amount of food very quickly, even when they’re not hungry, and often when they are alone to avoid embarrassment, according to the APA. Binge Eating Disorder is not to be confused with bulimia nervosa, which involves, in addition to binge eating, purging behaviors like vomiting.


The revised manual stipulates that binging or purging just once a week qualifies for the diagnosis, rather than biweekly.

Rapid Eye Movement Sleep Behavior Disorder

In his 2012 autobiographical film “Sleepwalk With Me,” the comedian Mike Birbiglia brought attention to this disorder, often called REM behavior disorder, which causes him to act out his dreams in real life.


The phenomenon became particularly problematic for Birbiglia after he jumped through a second-story hotel window in a dream about escaping a missile, landing him in the emergency room with glass wounds. (The disorder differs from typical sleepwalking in that people with REM behavior disorder usually remember what they were doing in the dream.)


Now, the disorder, which the DSM previously included ambiguously under parasomnia, gains official recognition by the clinical psychiatry community in addition to Hollywood.


The diagnosis, which the APA says is fully supported by research evidence, is often preceded by dream enactment episodes resulting in injury to the person or the partner with whom they share a bed.


In treating the condition, doctors may recommend removing sharp and dangerous objects from the bedroom and cushioning the area around the bed.

Restless Legs Syndrome

Given its solid neurological basis, some psychiatrists, including McHugh at Johns Hopkins, wonder why the disease, characterized by uncomfortable urges to move the legs when lying down, wasn’t given full DSM status long ago.


But scientific and genetic research have advanced the medical knowledge of the disorder, which is now also identified as Willis-Ekbom disease, since the previous version of the DSM.


While about 2% to 3% of adults are severely affected by it, up to 10% of people in the U.S. may have it, according to the Willis-Ekbom Disease Foundation (formerly the Restless Legs Syndrome Foundation).


By giving official diagnostic status to the disorder, which was previously classified as a “not otherwise specified” form of dyssomnia, the DSM-5 may promote more precise diagnoses and treatment of restless legs syndrome, psychiatrists say.




Major Neurocognitive Disorder with Lewy Body Disease and Mild Neurocognitive Disorder

With these additions, the DSM-5 expands the category of dementia, the memory and cognitive impairment increasingly afflicting the aged:

About 14% of Americans age 71 and older have dementia, and the number is expected to double by 2050 because of the wave of baby boomers hitting 65, according to a new report by the Alzheimer’s Association.

The new diagnoses also allow psychiatrists to distinguish between different levels of dementia’s severity.

“The psychiatry group is waking up to what the neurologists have been classifying and recognizing for a long time,” says McHugh, the Johns Hopkins psychiatrist.

Still, the “threshold” between mild and major neurocognitive disorder “is inherently arbitrary,” the APA admits. (The newly added mild version was mentioned in an appendix of the DSM-4 for conditions needing further study.)


But by differentiating between them, the DSM-5 could pave the way for the diagnosis and treatment of “less disabling” cognitive impairment that could be nonetheless problematic for people and their families, according to the APA.

Disinhibited Social Engagement Disorder

This disorder can often be mistaken for ADHD, attention deficit/hyperactivity disorder, but the DSM-5 may reduce the confusion by adding it to the list of official diagnoses.


While children with disinhibited social engagement disorder can be inattentive and impulsive, the disorder may stem from inadequate care-giving and neglect. This disorder was previously grouped with reactive attachment disorder, children who have it may not actually lack attachments, according to the APA.


The separate classification allows for different clinical interventions and treatment plans.

Central Sleep Apnea and Sleep-Related Hypoventilation

The DSM has long struggled to classify sleep disorders, especially those that related to problems with breathing while sleeping.


The growing share of the population with diabetes and cardiovascular disease, which studies have shown to increase the risk of central sleep apnea and other breathing-related sleep disorders, may make it more important to precisely identify the problems.


But the medical community has also learned much more about these conditions since the previous DSM edition, enabling the new diagnoses:

“This change reflects the growing understanding of pathophysiology in the genesis of these disorders and, furthermore, has relevance to treatment planning,” according to the APA’s guide to the changes in the DSM-5.