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Text of Divisive Psychiatric Manual Finalized

On Saturday, the board of trustees of the American Psychiatric Association (APA) voted to approve the final text of the DSM-5, the next revision to the leading manual for diagnosing mental illness. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, which originated in 1952, will be released next May at the APA's annual meeting in San Francisco. The revision process leading to DSM-5 began in 1999, and APA says it consulted more than 1500 experts in 39 countries in updating the criteria for diagnosing hundreds of psychiatric conditions. It has been a bumpy ride.

Controversy has dogged the revision process for years. Even before the first draft of proposed changes was released in 2010, critics alleged that too much of the deliberation was conducted in secret and that too many of those involved had ties to drug companies that stood to benefit from changes to diagnostic criteria—APA has repeatedly rejected these charges.

And many of the diagnostic proposals have elicited a strong reaction. A proposal to combine several autism-related disorders into a single diagnosis raised concerns among some critics that it would radically alter who gets diagnosed with those disorders and angered advocates for Asperger syndrome, a milder form of autism that would be eliminated in the new scheme. A new childhood condition called disruptive mood dysregulation disorder, characterized by irritability and violent outbursts, was intended to stem the perceived overdiagnosis of childhood bipolar disorder, but critics have argued that the diagnosis lacks scientific validity. Yet another controversial proposal, to remove language that excludes people who've recently experienced the loss of a loved one from being diagnosed with major depression, elicited complaints that it would lead to the medicalization of normal grief. These changes will stand, APA said in a press release.

APA, however, has recently backed down from other proposals, including "attenuated psychosis syndrome," a precursor to schizophrenia. The APA work group on psychotic disorders had hoped this diagnosis could help clinicians identify people at risk and intervene before they developed full-blown schizophrenia, but they ultimately abandoned it over concerns that clinicians would be unable to make the diagnosis reliably and consistently.

In a statement, APA President Dilip Jeste acknowledged the challenges the organization had faced in attempting to create a science-based diagnostic manual and the "inevitable disagreements about some of the proposals." Even so, he concluded: "We believe that DSM-5 reflects our best scientific understanding of psychiatric disorders and will optimally serve clinical and public health needs. Our hope is that the DSM-5 will lead to more accurate diagnoses, better access to mental health services, and improved patient outcomes."