Revising a book on disorders of the mind

Far fewer children would get a diagnosis of bipolar disorder. "Binge eating disorder" and "hypersexuality" might become commonly used labels for adults. And the way many mental disorders are diagnosed and treated would be sharply revised.

These are a few of the changes proposed on Tuesday by doctors charged with revising psychiatry's encyclopedia of mental disorders, the guidebook that largely determines where society draws the line between normal and not normal, between eccentricity and illness, between self-indulgence and self-destruction — and, by extension, when and how patients should be treated.

The eagerly awaited revisions — to be published, if adopted, in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, due in 2013 — would be the first in a decade.

For months they have been the subject of intense speculation and lobbying by advocacy groups, and some proposed changes have already been widely discussed — including folding the diagnosis of Asperger's syndrome into a broader category, autism spectrum disorder.

But others, including a proposed alternative for bipolar disorder in many children, were unveiled on Tuesday. Experts said the recommendations, posted online at DSM5.org for public comment, could bring rapid change in several areas.

"Anything you put in that book, any little change you make, has huge implications not only for psychiatry but for pharmaceutical marketing, research, for the legal system, for who's considered to be normal or not, for who's considered disabled," said Dr. Michael First, a professor of psychiatry at Columbia University who edited the fourth edition of the manual but is not involved in the fifth.

"And it has huge implications for stigma," First continued, "because the more disorders you put in, the more people get labels, and the higher the risk that some get inappropriate treatment."

One significant change would be adding a childhood disorder called temper dysregulation disorder with dysphoria, a recommendation that grew out of recent findings that many wildly aggressive, irritable children who have been given a diagnosis of bipolar disorder do not have it. The misdiagnosis led many children to be given powerful anti-psychotic drugs, which have serious side effects, including metabolic changes.

"The treatment of bipolar disorder is meds first, meds second and meds third," said Dr. Jack McClellan, a psychiatrist at the University of Washington who is not working on the manual. "Whereas if these kids have a behavior disorder, then behavioral treatment should be considered the primary treatment."