Just as primary and specialty care physicians change their diagnostic and treatment methods as research uncovers better ones, so to do mental health providers.

The Diagnostic and Statistical Manual of Mental Disorders, commonly referred to as DSM, is the gold standard for mental disorders used by mental health and other health professionals for diagnostic and research purposes. The current edition, the manual's fourth, was published in 1994, with some text revisions published six years afterwards. The American Psychiatric Association (APA) has, 10 year later, released the proposed diagnostic criteria for the upcoming fifth edition.

"These draft criteria represent a decade of work by the APA in reviewing and revising DSM," said Alan Schatzberg, M.D, president of the association. "But it is important to note that DSM-V is still very much a work in progress--and these proposed revisions are by no means final."

Which means DSM-V won't be hitting bookshelves just yet. The proposed changes are available for public comment until April 20, 2010. After that, the proposed criteria will be reviewed and refined over the next two years. During this time, the APA will conduct three phases of field trials to test some of the proposed diagnostic criteria in real-world clinical settings.

Some of the proposed revisions represent a fairly significant shift in thinking and understanding of some mental health disorders, and some have already stirred some controversy. Again, these revisions are just drafts and may be overhauled or rejected altogether before 2013.

Substance Abuse and Dependence

The proposed diagnostic criteria eliminate the current categories of substance abuse and dependence and replaces them with the new category "addiction and related disorders." This category would include "substance use disorders," with each drug identified as a category, such as "alcohol use disorder."

The Substance-Related Disorders Work Group members also have recommended a new category for behavioral addictions, in which gambling would be the sole disorder.

"The field of substance abuse and addiction has witnessed an explosion in important research in the past two decades," said David Kupfer, M.D., chair of the DSM-V Task Force. "These work group recommendations reflect the best science in the field and provide new clarity in how to diagnose these disorders."

The proposed criteria for substance use disorder are very similar to those now used to describe substance abuse and dependence in DSM-IV, although categories of "moderate" and "severe" would be added to describe severity. The symptom of drug craving would also be added, and the symptom of problems with law enforcement would be eliminated because of cultural considerations that make the criteria difficult to apply internationally.

"The term dependence is misleading because people confuse it with addiction, when in fact the tolerance and withdrawal patients experience are very normal responses to prescribed medications that affect the central nervous system," said Charles O'Brien, M.D., Ph.D., chair of the Substance-Related Disorders Work Group. "On the other hand, addiction is compulsive drug-seeking behavior, which is quite different. We hope that this new classification will help end this widespread misunderstanding."

Dr. O'Brien also explained the work group's reasoning behind the new category of behavioral addiction: "There is substantive research that supports the position that pathological gambling and substance use disorders are very similar in the way they affect the brain and neurological reward system," he said. "Both are related to poor impulse control and the brain's system of reward and aggression."

The proposed revisions also include a separate category that's not part of substance use disorder: "miscellaneous discontinuation syndromes." Withdrawal syndromes occur when a person has been taking a substance that's affected the central nervous system, and those cells have adapted over time to reduce their response to the substance. "If the substance is abruptly discontinued, in some cases the body responds with a rebound effect that creates unpleasant--and sometimes serious--symptoms of withdrawal," said Dr. O'Brien.

Assessment for Suicide Risk

The fifth edition's proposed diagnostic criteria include a new suicide assessment tool, developed to help clinicians better identify individuals at risk for suicide. A new "risk syndromes" category, which would include the two new diagnoses of psychosis risk syndrome and minor neurocognitive disorder, also has been proposed.

Two new scales have been proposed for assessing individuals' risk factors for committing suicide: one for adolescents and one for adults. While the current version of DSM includes thoughts of suicide as a symptom of some mental disorders, such as major depression, the proposed suicide risk techniques have been designed to be applied to anyone receiving an evaluation for a mental disorder, regardless of diagnosis, to help health care providers identify those patients at risk for suicide.

Said David Shaffer, M.D., a member of the Disorders in Childhood and Adolescence Work Group, "The use of a single research-based scale and accompanying record of assessment may help clinicians better assess suicide risk, as well as provide important information for researchers to help us more accurately identify and treat those at greatest risk for suicide."

The proposed scales are based on research identifying significant risk factors for suicide from follow-up studies and from "psychological autopsies" in which the past history of suicides and closely matched controls were compared.

The assessment tool for adolescents consists of a series of questions answered on paper or on a computer, methods found to be better than in-person questions for obtaining truthful answers about planned suicide in teens. The risk factors to be sought in adults include detailed planning of a potential suicide, chronic severe pain or illness, high or increased alcohol use, worsening of depression, increased anxiety and agitated behavior.