2010 Conference - Proposed Changes for DSM-V (O'Brien)

Charles P. OʼBrien, MD, PhD"University of Pennsylvania"

DIAGNOSTIC & STATISTICAL MANUAL

Edition" Year" Pages" Categories"

I" 1952" 132" 106"II" 1968" 119" 182"III" 1980" 494" 265"

III-R" 1987" 567" 292"IV" 1994" 686" ~300"V" 2013" -" -"

Criteria should be"

•  For Clinicians

•  Easy to Use

•  Reliable & Valid

•  Good Coverage

PHILOSOPHY"

•  Decide Using Data •  Change When Justified •  Base Decision On: Value Added Cohesive Structure Coverage

Proposed DSM-5 "Clustering"

Neurodevelopment disorders" Developmental impairments in cognition or social cognition"

Autism, Learning Disabilities, Intellectual Disability"

Neurocognitive disorders" Dementias, Delirium"

Schizophrenia and related disorders"

Schizotype with or without psychosis" Schizophrenia, Schizotypal personality disorders, some nonaffective psychoses"

Mood Disorders" Predominant disturbance of mood regulation"

Depression, GAD, Bipolar disorder"

Anxiety Disorders" Predominent dysregulation of fear" Panic disorder, social phobia, simple phobias, PTSD"

Obsessive Compulsive Disorders"

Unwanted intrusive thoughts or motor behaviors: In OCD, compulsions to manage the resulting tension"

OCD, Touretteʼs, BCC, possibly trichotillomania, possibly hypochondria"

Substance use, addiction and related disorders"

Pathological reward-seeking. Imbalance between reward circuitry and cognitive control (PFC)"

Substance addictions, compulsive gambling, possibly other compulsive behaviors"

Impulse Control Disorders" Pathological failure to control inappropriate cognitive, emotional, or behavioral responses"

ADHD, CD, ODD, Intermittent explosive disorder; perhaps paraphilias; perhaps binge eating"

Somatic Disorders" Eating, Sleep, Sexual, Somatic Disorders"

Personality Disorders"

Symptom Changes"

Craving"

Gambling"

•  Move pathological gambling from ICD-not otherwise specified to a “substance use and related disorders” section."

•  Change the name of the disorder (e.g., “disordered gambling”)."

•  Reduce the threshold to 4 of 9 criteria and eliminate the legal criterion item "

Other putative “addictions”!

•  Internet Addiction (insufficient data) "

•  Sexual (sexual use disorders committee is evaluating; not sufficient evidence that it is similar to other non-substance related addictions)"

•  Eating (some overlap with substance use disorders and putative associations with eating disorders)"

•  Shopping (some empirical data available)"

•  Work (minimal data available)"

•  Exercise (minimal data available)"

Addiction: A Brain Disease

•  Genetic vulnerability, e.g. 40-80% heritability

•  Biological risk factors, e.g. anhedonia

•  Brain abnormalities, e.g. low DA density NcA

•  Effective neurobiological interventions

Comorbidity PG-SUD Petry, 2007

•  >25% of treatment-seeking pathological gamblers also have a substance use disorder

•  5-20% of treatment-seeking substance abusers also have pathological gambling (LTPcommunity 0.4-2%)

•  General population studies also show high rates of PG-SUD comorbidity

•  US and non-US studies

Considerations for including new disorders in DSM-V"

•  A clinical need"•  Sufficiently distinct from other

disorders"•  Potential harm (to other patient or non-

patient groups)"•  Potential for treatment"•  Meets criteria for a mental disorder"

Prevalence rates of “gaming” addiction *modified

Proportion of adolescents reporting DSM-IV symptoms for Internet “addiction” (Ko et al., 2005)

Limitations

! Usually non-random convenience samples (school surveys or on-line respondents, with limited representation of middle or older aged adults).

! Response biases. ! Different instruments with limited psychometric

testing (Buyn et al., 2009).

! Lack of a general agreement as to what constitutes Internet/gaming addiction.