3. The behavior and its consequences cause clinically significant distress or impairment in interpersonal, academic, or other important areas of function. (This criterion is tentative.)
4. Self-injury does not exclusively occur during states of psychosis, delirium, or intoxication. In people with a developmental disorder, the behavior is not part of a pattern of repetitive stereotypies.
The behavior cannot be attributed to another mental or medical disorder, such as psychotic disorder, pervasive developmental disorder, mental retardation, or Lesch-Nyhan syndrome.
The proposed criteria also establish a subthreshold diagnosis, if all other criteria are met but self-injury occurred fewer than five times during the past 12 months, in people who frequently think about performing self-injury but infrequently do it.
Patients who meet the NSSI criteria and express an intent of achieving relief or positive feeling, but who also intend to commit suicide, meet criteria as an “intent uncertain” form of NSSI.
“The issue is failure to recognize NSSI as benign,” Dr. Shaffer said in an interview. “I think [the new diagnosis] will safely avert hospital admissions. Although some of these youngsters will, at certain times, make suicide attempts, an episode of cutting doesn't mean that they need hospitalization, which can be a traumatizing and damaging process.”
In addition, keeping patients with NSSI out of hospitals will prevent the contagion that often results. (Introduction of a child or adolescent who has self-mutilated in a hospital ward often leads to an outbreak of similar behavior among others in the ward.)
Dr. Leibenluft, Dr. Pine, and Dr. Shaffer had no relevant financial disclosures.
Dr. Ellen Leibenluft says the new temper dysregulation disorder diagnosis would create a niche for an important group of patients.
'Until there are systematic treatment studies, we won't know' how to best manage these patients.
'My hope is that [the new diagnosis of TDD] will decrease the number of kids who get labeled with bipolar.'
Source DR. SHAFFER
Sweeping Changes to DSM-5 Proposed
Members from various work groups of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders presented the following tentative changes that involve pediatric psychiatric diagnoses:
▸ Children and Adolescents in DSM-5. Most fundamentally, the DSM-5 might drop the “disorders usually first diagnosed in children and adolescents” category. Those disorders now are generally split between the neurodevelopmental disorders group and the disruptive behavior disorders group. Other likely, sweeping changes include eliminating definitions based on etiology and increasing focus on development, said Dr. Pine, who also chairs the DSM-5 Childhood and Adolescent Disorders Work Group.
▸ Feeding and Eating Disorders. The DSM-5 might eliminate the previous category of feeding and eating disorders of infancy or early childhood. All of the specific disorders previously listed in the category would shift into a newly named category: feeding and eating disorders. The category includes pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, and “conditions not elsewhere classified,” which will include atypical anorexia nervosa, purging disorder, and night eating syndrome.
Avoidant/restrictive food intake disorder is a new name for what the DSM previously called feeding disorder of infancy or early childhood. The purpose of the change “is to reduce the not-otherwise-specified diagnoses, and to give a landing place for a lot of kids who have eating problems but no place to land in DSM-IV,” said Dr. B. Timothy Walsh, professor of pediatric psychopharmacology at Columbia University in New York. “What we're proposing [for this diagnosis] will be a heterogeneous collection” of patients. A key factor in making the avoidant/restrictive diagnosis is that “it has to have significant consequences, because a lot of these behaviors occur normally in kids growing up,” he said.
▸ Reactive Attachment Disorders. This diagnosis now lists two forms: inhibited and disinhibited. Current proposals will change this to two separate diagnoses. “Reactive attachment disorder” will apply exclusively to the inhibited form, for withdrawn patients with emotional unresponsiveness. The disinhibited, indiscriminately social form would receive the new name “disinhibited social engagement disorder.” One reason for such a change is that the disinhibited form “is not related to level of social attachment,” said Dr. Charles H. Zeanah, professor and director of child and adolescent psychiatry at Tulane University in New Orleans.
▸ Posttraumatic Stress Disorder. The diagnosis criteria would change to deal with the large number of preschool children who cannot meet current criteria despite being highly symptomatic. In particular, the work group proposes changing the avoidance and numbing criteria, because until now, few children met those criteria. The revision lists avoidance and numbing separately, and proposes changing numbing to “negative alterations in mood or cognition.”