Controversial disorders left out of DSM-5

Gender identity disorder, attenuated psychosis syndrome and internet addiction will not after all be classed as psychiatric disorders, the DSM-5 authors have announced.

Also denied places in the controversial update of psychiatry’s ‘diagnostic bible’ — having previously been proposed for inclusion — are mixed anxiety-depression, generalised anxiety disorder, hypersexual behaviour and persistent complicated bereavement disorder.

The near-final drafts of DSM-5, and the results of field trials, were unveiled last week at the American Psychiatric Association’s annual conference in Philadelphia, US.

New diagnoses that did make the cut include premenstrual dysphoric disorder, disruptive mood dysregulation disorder in children, and autism spectrum disorder (a single condition combining the previous diagnoses of autism, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified.).

There are also several other changes to diagnostic processes, including the use of dimensional assessments, biomarkers and a greater emphasis on functional impairment in diagnoses.

Last week’s conference represents a key milestone in the long process of revising DSM-IV, which began in 1999 and is due to culminate next May when the final edition of DSM-5 is launched.

The revision process has been beset by controversy, with critics claiming some of the proposals could lead to over-diagnosis and medicalisation of normal behaviours. Over 13,000 people, including several Australian psychiatrists and psychologists, have signed an online petition protesting the changes.

However many of the new diagnoses have performed well so far in field trials, members of the DSM-5 task force said.

These trials check whether different doctors, with minimal training, could use the same proposed criteria to reach the same diagnosis for any given patient. They have been conducted at 11 sites across the US and Canada, involving about 3,500 patients either meeting DSM-IV criteria for one or more diagnoses up for revision in DSM-5, or exhibiting symptoms of these new diagnoses.

Reliability was graded on a scale from 0 to 1 (0.6-0.8 being excellent, and under 0.02 unacceptable), lead statistician Helena Kraemer told a packed auditorium at the conference.

While generalised anxiety disorder and developmental major depressive disorder scored a “disappointing” 0.2 and 0.29 respectively, there were also some “exciting, highly reliable” diagnoses, she said.

Major neurocognitive disorder was the best performer with reliability rating of 0.78. Diagnoses in the “very good” range were autism spectrum disorder (0.69), attention deficit hyperactive disorder (0.61) and post-traumatic stress disorder (0.67).

Surprisingly major depressive disorder had a poor rating of 0.32, despite only slight alterations from the DSM-IV version, according to Professor Jan Fawcett, head of the work group in charge of depression.

"I was not happy with the [scores] that came out, but it might be that that is the reliability of [diagnosing MDD] in the real world," he said.

Other proposed diagnoses, including attenuated psychosis syndrome, obsessive-compulsive personality disorder, antisocial personality disorder and non-suicidal self-injury, performed poorly and will be relegated to the DSM-5’s appendices, warranting further research.

Ms Aubusson attended the American Psychiatric Association conference for Australian Doctor’s sister publication Psychiatry Update, courtesy of an independent educational grant from Pfizer mental health.