So what are psychiatrists saying around water coolers these days? Particularly those in the know on the DSM-5? In addition to Pitt’s David Kupfer, who served as the task force chair, several other Pitt people helped shape the new manual. We asked Pitt DSM work-group and task-force-folk if they could tell us, very briefly, what the big takeaways are from their respective chapters. Here’s what we learned.
—By Josie Fisher

For more detail, visit DSM-5 on the APA Web site.

Feeding and Eating Disorders

“One of the major changes is the addition of a new disorder, binge eating disorder, characterized by persistent and recurrent binge eating without the compensatory behaviors (e.g., purging, overexercising) seen in bulimia nervosa,” says Marsha Marcus, a PhD, professor of psychiatry and psychology in the School of Medicine, and chief of Western Psychiatric Institute and Clinic’s Behavioral Medicine Program. Marcus was a member of the Feeding and Eating Disorders Work Group. She notes that binge eating disorder differs substantially from common overeating: It is much less common, far more severe, and associated with significant physical and psychological problems. In addition, DSM-IV’s “feeding disorder of infancy or early childhood” is now “avoidant/restrictive food intake disorder,” because the condition is not limited to early childhood.

Sleep-Wake Disorders

A sleep-wake disorder can be a risk factor for certain mental conditions and a warning sign for serious medical issues, such as congestive heart failure, osteoarthritis, and Parkinson’s disease. To draw attention to this, DSM-5 criteria ask clinicians to list coexisting psychiatric and medical diagnoses, says Charles Reynolds III, an MD and the UPMC Endowed Professor in Geriatric Psychiatry who also directs the UPMC/Pitt Aging Institute. Reynolds chaired the DSM-5 Sleep-Wake Disorders Work Group and was a member of the DSM-5 Task Force. He says Sleep-Wake Disorders incorporate laboratory-based measures for diagnosis of breathingrelated sleep disorders (such as obstructive sleep apnea) and narcolepsy with hypocretin deficiency. The manual also now describes restless legs syndrome, REM sleep behavior disorder, and advanced sleep phase syndrome.

Mood Disorders

Pediatricians should know about the newly described disruptive mood dysregulation disorder in children. It’s characterized by extreme, persistent emotional outbursts many times a week, lasting at least a year, across multiple situations—at home, in school, at play, etc. Unlike normal temper tantrums, these episodes seriously impair functioning and, in between outbursts, the child is markedly sad or irritable, says Pitt’s Ellen Frank, a PhD and Distinguished Professor of Psychiatry and Psychology. Frank was a member of the DSM-5 Mood Disorders Work Group. She hopes that the newly articulated disorder will reduce misdiagnoses of childhood bipolar disorder— and the mismedication that goes along with it and jumpstart effective treatment.

Epidemiologic evidence shows that these kids grow up to have depression or anxiety, not bipolar disorders, says Frank. Bipolar and Related Disorders is its own chapter in DSM-5 (separate from Depressive Disorders), in part because neuroscience and genetic evidence suggest that bipolar disorder aligns more closely with schizophrenia and other psychotic disorders than with unipolar depressive disorders. Further, bipolar disorder criteria now urge clinicians to ask upfront about a patient’s changes in energy/ activity levels, in addition to asking about elevated, euphoric, or irritable moods. Data show that increased activity is an equally important marker, says Frank.

Neurocognitive Disorders

The label “neurocognitive disorders” refers to a cognitive impairment that’s a defining feature of a condition and acquired, rather than present from early childhood, says Pitt’s Mary Ganguli, an MD, MPH, professor of psychiatry, neurology, and epidemiology. Ganguli was a member of DSM-5’s Neurocognitive Disorders Work Group. She says the chapter describes major neurocognitive disorder, which encompasses the likes of “dementia” in geriatrics and “neurocognitive disorder” in other circumstances (e.g., young people with severe impairment from head trauma). In a move away from Alzheimer-centric criteria, depending on the cause of the impairment, “the domains that are impaired in neurocognitive disorders do not necessarily include memory,” says Ganguli.

Newly introduced is mild neurocognitive disorder, in which a person is less severely impaired. The patient still functions independently, albeit with greater effort and often relying on lists, reminders, and other compensatory mechanisms. This diagnosis has been criticized by some as medicalizing normal variation. In fact, psychiatrists have long recognized the condition though it was lumped into the “not otherwise specified” category in DSM-IV, Ganguli says. “With increasing focus on early detection and intervention, we need to be able to recognize and appropriately classify mild impairments.” She adds that it’s important to note that “mild” is not synonymous with “early”—the impairment may be a sign of further deterioration ahead, may stay as is, or it may even be reversible.

The chapter also offers further guidance on diagnosing underlying conditions—like HIV infection, cerebrovascular disease, or Alzheimer’s or Parkinson’s disease—that may be causing a given cognitive disorder. The scale at which this task was undertaken (with colleagues in general medicine, neurology, etc.) is unique to this edition of the manual, notes Ganguli, and a huge contribution.