What type of mental health problem is gambling addiction?
Is binge eating a mental illness?
Should autism be considered one catch-all disorder or fall under different labels indicating its severity?
Those are just some of the questions that scores of mental health professionals wrestled with for nearly a decade, as they conducted their periodic update of the neuroses of an evolving society.
The result of their work was unveiled by the American Psychiatric Association last week, as a draft version of the new "Diagnostic and Statistical Manual of Mental Disorders."
Known as the DSM-5, because it represents the fifth edition of this exhaustive bible for psychiatrists, psychologists and others, it attempts to catalog everything from Complex Somatic Symptom Disorder (related to hypochondria) to Temper Dysregulation Disorder with Dysphoria (persistently very ill-behaving children).
The first update since 1994 also includes descriptions of depression, sleep disorders, alcohol abuse and other common maladies, but everything gets a fresh look because of the volume of new research and science affecting how they're all regarded, said David Kupfer, the University of Pittsburgh psychiatry professor who chaired the DSM-5 task force.
The final product will go into the offices of all sorts of health professionals -- from psychiatrists to family practitioners -- while also influencing treatment payments by insurance companies, drug development by the pharmaceutical industry and future research by government and academia.
Dr. Kupfer, the longtime head of Pitt's psychiatry department before stepping down in October, said the manual remains a work in progress, with revisions based on public and professional reaction before final publication in 2013.
"We weren't out to make major changes, but so much has happened that we needed to address, that some may accuse us of being overambitious," he said.
The Shadyside resident, 69, has been nationally noted for his work on depression at Western Psychiatric Institute and Clinic. He headed a task force of some 160 international researchers and clinicians who worked on DSM-5, with 13 work groups covering various topic areas.
Among the pronouncements in the draft version:
• All forms of autism will fall under a single diagnostic category, called "autism spectrum disorders," a concept that drew quick criticism from representatives of those with the Asperger's form of autism, who are often high functioning.
• Gambling, identified as an "impulse control disorder" since 1980, will be moved into a "behavioral addiction" category that reflects its similarities to drug and alcohol addiction. Certain other addictions, such as excessive use of the Internet, were considered for the category but denied placement there because of insufficient research data.
• Binge eating is recognized as a disorder for the first time, similar to anorexia and bulimia.
• Mental retardation is to be relabeled as "intellectual disability."
At www.dsm5.org, those interested can obtain detailed information about the draft manual recommendations and provide comments.
Dr. Kupfer, who focused on sleep disorders as part of the DSM-4 task force, said there is intense discussion during every update about what problems merit entering the manual for the first time.
There was consideration of hoarding this time as a mental health issue, but it failed to make it into the recommendations for full manual treatment. There are always lobbyists for parental alienation syndrome, but they did not win out this time either.
Some issues are close enough to legitimate recognition that they end up listed in the manual's appendix, as binge eating was previously, and where Internet addiction is likely headed.
"The door to get in [the manual] is pretty hard," Dr. Kupfer said. "Once you're in the club, it's then hard to get out. All of us are a little tight about admitting people in the club."
He expects more flexibility for the manual than the past, however, from being able to use the flow of comments over the Internet to alter the recommendations over the next couple of years and even make changes after the 2013 publication.
By example, Dr. Kupfer said, "We would have loved to change 'mental retardation' a lot sooner to 'intellectual disability,' which is playing catch-up" with terminology already used in that field.
More than 1,000 public comments poured forth in the first 24 hours after the new recommendations came out, he said.
The psychiatrist said the work on the spectrum of mental health issues seeks neither consensus -- which he said sinks to the "lowest common denominator" -- nor catering to those "who scream the loudest."
"If you work with clinicians and researchers in psychiatry together and show them data and raise questions and have good sessions," he suggested, "I think we can pretty much come to reasonable agreement."
However, it's not always clear what the agreements lead to.
Pathological gambling, for instance, has been recognized by the American Psychiatric Association as a disorder since its DSM-3 manual came out three decades ago. Yet, most health insurers still decline to cover compulsive gambling treatment in their policies, noted Keith Whyte, executive director of the National Council on Problem Gambling.
There's no certainty that shifting gambling to a different category in the DSM-5 will mean anything different to insurers, but there is at least more general recognition of compulsive gambling as a psychiatric disorder than in the past, said Nancy Petry, director of the Gambling Treatment Research Center at the University of Connecticut Health Center.
"As there's been more research, it's really quite evident it has a high rate of co-morbidity with substance abuse disorders and shares a lot of features with them," and so will be compared in the manual closely to drug and alcohol addiction, said Dr. Petry, who chaired the DSM-5 subcommittee reviewing gambling.
Gary Rotstein: firstname.lastname@example.org or 412-263-1255.