The DSM-5 proposed diagnostic criteria have been put out for public view, in advance of field testing, on www.DSM5.org. While the proposed changes are many, those most pertinent to child psychiatry are described below.
Temper Dysregulation Syndrome with Dysphoria. One big controversy is the possible inclusion of temper dysregulation syndrome with dysphoria (TDSD), an attempt to provide a more precise diagnostic home for kids who now are often classified as having bipolar disorder. Proposed diagnostic criteria for TDSD include out of proportion reactions to normal stressors, including violence or rage, occurring at least three times a week; a baseline mood of unhappiness for 12 months or more; and the absence of episodes of mania or hypomania.
The controversy over TDSD reflects a longstanding debate in the field between those who argue that chronic irritability is a pediatric bipolar marker—so-called “broad criteria” or “broad spectrum” view—versus those who argue that childhood mania is defined by classic symptoms, such as euphoria and grandiosity (so called “narrow criteria”). (For more on this topic, see this month’s research update “Pediatric BD vs. SMD”) The DSM-5 committee’s proposed diagnostic change is more in line with the view that irritability alone is not a bipolar disorder marker. This diagnosis will be somewhat difficult to differentiate from oppositional defiant disorder as it is proposed for the DSM-5, the wording of which is: “angry and irritable mood along with defiant and vindictive behavior.”
Attention Deficit and Disruptive Disorders. The specifiers “predominantly inattentive” and “predominantly hyperactive/impulsive” may be discontinued with new scales used to describe the nature of the behavior. Alternatively, a new diagnosis, “attention deficit disorder” (as opposed to ADHD), may be created. Minimum age of onset would be broadened from seven to 12, and the number of criteria required to make the diagnosis in adults would be decreased from six to three.
Autistic Spectrum Disorder. A new disorder, autistic spectrum disorder, would replace Asperger’s disorder, childhood disintegrative disorder, pervasive developmental disorder NOS and autistic disorder; Rett’s disorder would be eliminated. The rationale is that while it is fairly easy to differentiate patients on the spectrum from those not on the spectrum, the individual disorders differentiate poorly and create more confusion than clarity.
Eating Disorders. The eating disorders section would be renamed to eating and feeding disorders, to account for the addition of pica, rumination, and feeding disorder of infancy and childhood. Binge eating disorder would be moved from the appendix to this section as well, meaning that it is now a bona fide DSM-5 disorder. The diagnostic criteria for anorexia nervosa would allow for B criteria to include persistent weight loss behavior in lieu of the stated fear of gaining weight. The amenorrhea criterion for anorexia nervosa would be discontinued and stated fear of gaining weight would not be required. Bulimia nervosa criteria would be loosened to require only weekly binges and purges rather than twice weekly.
Non-Suicidal Self Injury. This proposed diagnosis, non-suicidal self injury, is an attempt by the DSM-5 study group to differentiate frequent cutters (and scratchers and burners) from patients with suicidal intent or borderline personality disorder. The rationale for this category is that most patients who cut do not meet criteria for borderline personality disorder but instead have a variety of different diagnoses.
Other Proposed New Disorders. There are about a dozen disorders proposed by groups outside of the APA that are under consideration, including sensory processing disorder, fetal alcohol syndrome, parent alienation syndrome, and developmental trauma disorder. Whether these diagnoses will be incorporated or not remains to be seen, as does the specific diagnostic criteria. They look to be in the “probably not” category, but are not entirely ruled out either.