New disorder for children labelled ‘bipolar’ proposed

Dara Gantly examines some of the headline changes suggested in the draft criteria for DSM-5

Publication of the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in May 2013 will mark one the most anticipated events in the mental health field.
Earlier this month, the American Psychiatric Assoc-iation (APA) published its preliminary draft revisions to the current diagnostic criteria for psychiatric diagnoses for public review and comment.
Included was a single category called autism spectrum disorders that would incorporate Asperger’s syndrome; a category called behavioural addictions, in which gambling would be the sole disorder; and a recognition of binge-eating disorder.
The draft guidelines have proposed a new disorder for those children labelled ‘bipolar’. A proposed new diagnostic category, temper dysregulation with dysphoria (TDD), has been suggested within the Mood Disorders section of the manual.
Bipolar disorder
In its 11-page justification of the new TDD, the APA acknowledged that one of the most dramatic developments in child psychiatry in the past decade has been a marked upsurge in the rate at which children are being assigned the diagnosis of bipolar disorder.
The new criteria are based on a decade of research on severe mood dysregulation, and may help clinicians better differentiate children with these symptoms from those with bipolar disorder or oppositional defiant disorder.
Another interesting change is the proposal for a ‘risk syndromes’ category to help identify earlier stages of disorders like dementia and psychosis.
The proposal for a psychosis risk syndrome is still under discussion and the work group hopes to gather significant feedback from the public about this recommendation.
In explaining the rationale for the move, the APA clearly states that early signs and symptoms of schizophrenia, for example, are present years before diagnosis is established and can be predicted even in infants.
Also, the Association believes prevention science requires application. “It seems reasonable to anticipate that mental disorders will gradually develop interventions for primary and secondary prevention associated with a number of disorders,” it stated on the website dedicated to the revision process (www.dsm5.org).
Immediate issues relate to the unanswered question as to whether ordinary users of DSM-5 in ordinary settings will be able to reliably and validly identify cases based on criteria developed and validated by expert investigators. “Any movement forward with this proposal will depend on affirmative answers to this issue in field trials,” the Association explained.
A second problem relates to the absence of an evidence-based intervention which has demonstrated benefit in reducing conversion to psychosis. Finally, more information regarding the potential negative effect on false positive identification is needed.
New suicide scales
Other headline changes proposed include new suicide scales for adults and adolescents to help clinicians identify those individuals most at risk, with a goal of enhancing interventions across a broad range of mental disorders; the scales include research-based criteria such as impulsive behaviour and heavy drinking in teens.
Dimensional assessments
In addition to proposed changes to specific diagnostic criteria, the APA is proposing that ‘dimensional assessments’ be added to diagnostic evaluations of mental disorders. These would permit doctors to evaluate the severity of symptoms, as well as take into account ‘crosscutting’ symptoms that exist across a number of different diagnoses — such as insomnia or anxiety.
Final revisions to the new diagnostic criteria are due in 2012, with the release by the Association of the final, approved DSM-5 expected in May 2013.