Why would almost 11,000 Americans write letters in protest to the American Psychiatric Association about proposed changes in a scholarly book?

The reason is that even one small change in the Diagnostic and Statistical Manual of Mental Disorders, sometimes called the “psychiatrists’ Bible,” shakes up the entire medical establishment, insurance industry, and educational community. And the new edition of the DSM, due to come out in May 2013, is full of major changes in the way doctors will diagnose and treat mental disorders, psychiatric illnesses, and addiction. Some of the proposed changes mean that insurance companies will no longer cover certain illnesses, but they will be paying for newly-recognized ones, and that public school systems may be forced to eliminate many special education services, because fewer children will be diagnosed with autism and attention deficit disorder.

Some of the biggest changes are in the field of addiction. Perhaps the most surprising one of all is that the word “addiction” will appear in the new edition. In the DSM-Edition 4, which came out in 1993, psychiatrists did not recognize the term addiction, but rather two levels of what was called “substance disorders.” The first level was “substance abuse,” and in order to be diagnosed with that a patient needed to have one out of four symptoms over a one-year period. These are failure to fulfill major role obligations at work, school, or home, getting into trouble with the law, getting into physically hazardous situations, and having problems in relationships because of substance abuse. The second level was “substance dependency,” in which a patient had to have three or more of the following symptoms over a one-year period — physical tolerance to drugs or alcohol, withdrawal syndrome, drinking or drugging in larger amounts than intended, neglecting other activities because of substance abuse, recurrent efforts to cut down or eliminate the substance, spending too much time in activities related to the substance, and continuing use even though the person has knowledge of adverse consequences.

New Definition of “Addiction”

The new book eliminates the entire category of “substance dependency,” which originally passed into the old DSM by only one vote among those committee members who authored the book. The new DSM recognizes only “Addiction” with various subcategories such as “cocaine addiction,” “heroin addiction,” “alcohol addiction,” and so forth. The new symptoms include “drug or alcohol craving” and “the loss of control over the urge to take that substance.” The criterion of legal complications as a result of substance abuse was removed.

The main reason for this radical change is that many people become physically dependent on drugs that are prescribed to them. They undergo withdrawal symptoms when they stop taking them, but yet they are not addicted them. They do not necessarily have drug cravings, and they are not be part of a drug subculture or lifestyle. In order to cover this disorder, the new draft of the DSM-5 includes “Discontinuation Syndrome,” a new illness defined not as an addiction, but simply withdrawal from any psychoactive substance.

The new DSM would mandate primary care doctors to screen for addiction in order to save money in the long run. For example, if you treat an alcoholic in the early stages of the illness, you may help that person avoid an expensive liver transplant. Proposed changes to the new edition also include disorders called “risk syndromes,” to help physicians better identify which patients are at risk for which disorders in the future. It may also describe levels of severity of not only addiction, but other mental disorders as well.

The latest draft of DSM-5 has only one behavioral-based addiction, and that is pathological gambling. However, in another major change, “Internet addiction” appears in the appendix of DSM-5. There was not enough empirical evidence to recognize it as a psychiatric disorder, even though it is recognized in other countries. For example, people in China are often hospitalized for Internet addictions. Addictions to shopping, eating, working, and exercise were rejected for the DSM-5 because of lack of reliable data.

Hypersexuality But Not Sex Addiction

DSM-5 may include “hypersexuality” or “hypersexual disorders”  but not “sex addiction” as a mental disorder, a decision that puzzles many therapists. A hypersexualized person can engage in sexual activities many times a day without jeopardizing relationships or career, but sexual addicts are usually defined as people with out-of-control behaviors.

As one therapist and author wrote, “If you are a politician who hangs out at turnpike rest stop, picking up strangers (like the former governor of New Jersey), you are likely to get into all kinds of trouble. The problem is the combination of the risky and the life-disruptive nature of the behavior, not the frequency or intensity of sexual urges and intercourse.”

Other changes in the DSM will also affect the field of addiction treatment because the vast majority of addicts have comorbidities, defined as psychiatric illnesses that “travel” with addiction. For example, having attention deficit disorder/hyperactivity, an eating disorder, or bipolar disorder increases your risk for substance abuse. The new DSM changes the criteria for all of these. The new DSM does away with “personality disorders” such as narcissism and paranoid personality disorder, but instead recognizes certain negative personality traits and types. Again, many of the people in treatment for alcoholism and drug abuse have been diagnosed with personality disorders.

Many children now diagnosed with bipolar disorder would instead be diagnosed with “temper dysregulation with dysphoria,” defined as having three or more temper tantrums daily. It is unclear whether this TDD increases the risk for substance abuse as an adult in the same way bipolar disorder does. Part of the reason for this change to DSM-5 is that between 1994 and 2003, the number of children diagnosed with bipolar disorder increased forty times over.

One of the more controversial additions to DSM-5 is “Grief or bereavement” as a subcategory under “depressive disorders.” If a person remains in severe grief two months after the death of loved one, he could be treated for depression, which again is a major risk factor or substance abuse.

Most of the people protesting changes to DSM-5 are parents of children with autism, attention deficit disorder, and other mental diseases. The new DSM would tighten up the criteria for diagnosis, and the parents are afraid their children will no longer be eligible for services and insurance payments.

DSM-5 Authors Try to Answer Critics

Dr. Thomas Salmon, who founded the American Psychiatric Association in 1884, was a pioneer in developing a scientific system of diagnosis that imitates the language of medical treatment for physical diseases. He helped write the first DSM in 1917, and since then, there have only been three updates. For the new DSM-5, over 400 international researchers took part in 13 conferences held since 2000. In 2007, 160 clinicians formed the DSM-5 Task Force and Workgroup to draft it. There will also be two years of field testing before publication.

The problem in writing the DSM is that psychiatric illnesses cannot be defined with the same precision as physical diseases. The DSM-4, for example, actually says that it “makes no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or no other mental disorder.”

The DSM-5 Task Force has been criticized for everything from medicalizing normal conditions such as grief to eliminating certain diagnoses such as Asperger Syndrome. Dr. Charles O’Brien, the chair of the APA DSM Substance Related Disorders Workgroup, acknowledges the difficulty.

“This is going to produce big changes for all of us,” he said. “It is going to impact training programs, it is going to impact your practice, and it is going to impact patient reimbursement for services we provide and the drugs we prescribe.”

However, as APA President Dr. James Scully noted, “The world has changed since 1993,” and so must medicine.