DSM-5

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Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5)

Author	American Psychiatric Association
Country	United States
Language	English
Series	Diagnostic and Statistical Manual of Mental Disorders
Subject	Classification and diagnosis of mental disorders
Published	May 18, 2013
Media type	Print (hardcover, softcover); e-book
Pages	947
ISBN	978-0-89042-554-1
OCLC	830807378
Dewey Decimal	616.89'075
LC Class	RC455.2.C4
Preceded by	DSM-IV-TR

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the 2013 update to the Diagnostic and Statistical Manual of Mental Disorders, the taxonomic and diagnostic tool published by the American Psychiatric Association (APA). In the United States, the DSM serves as the principal authority for psychiatric diagnoses. Treatment recommendations, as well as payment by health care providers, are often determined by DSM classifications, so the appearance of a new version has practical importance. The DSM-5 is the first DSM to use an Arabic numeral instead of a Roman numeral in its title, as well as the first "living document" version of a DSM.

The DSM-5 is not a major revision of the DSM-IV-TR but there are significant differences. Changes in the DSM-5 include the reconceptualization of Asperger syndrome from a distinct disorder to an autism spectrum disorder; the elimination of subtypes of schizophrenia; the deletion of the "bereavement exclusion" for depressive disorders; the renaming of gender identity disorder to gender dysphoria; the inclusion of binge eating disorder as a discrete eating disorder; the renaming and reconceptualization of paraphilias, now called paraphilic disorders; the removal of the five-axis system; and the splitting of disorders not otherwise specified into other specified disorders and unspecified disorders.

Some authorities criticized the fifth edition both before and after it was published. Critics assert, for example, that many DSM-5 revisions or additions lack empirical support; inter-rater reliability is low for many disorders; several sections contain poorly written, confusing, or contradictory information; and the psychiatric drug industry may have unduly influenced the manual's content (many DSM-5 workgroup participants had ties to pharmaceutical companies).

Changes from DSM-IV

The DSM-5 is divided into three Sections, using Roman numerals to designate each Section.

Section I

Section I describes DSM-5 chapter organization, its change from the multiaxial system, and Section III's dimensional assessments. The DSM-5 deleted the chapter that includes "disorders usually first diagnosed in infancy, childhood, or adolescence" opting to list them in other chapters. A note under Anxiety Disorders says that the "sequential order" of at least some DSM-5 chapters has significance that reflects the relationships between diagnoses.

The introductory section describes the process of DSM revision, including field trials, public and professional review, and expert review. It states its goal is to harmonize with the ICD systems and share organizational structures as much as is feasible. Concern about the categorical system of diagnosis is expressed, but the conclusion is the reality that alternative definitions for most disorders are scientifically premature.

DSM-5 replaces the NOS (Not Otherwise Specified) categories with two options: other specified disorder and unspecified disorder to increase the utility to the clinician. The first allows the clinician to specify the reason that the criteria for a specific disorder are not met; the second allows the clinician the option to forgo specification.

DSM-5 has discarded the multiaxial system of diagnosis (formerly Axis I, Axis II, Axis III), listing all disorders in Section II. It has replaced Axis IV with significant psychosocial and contextual features and dropped Axis V (Global Assessment of Functioning, known as GAF). The World Health Organization's (WHO) Disability Assessment Schedule is added to Section III (Emerging measures and models) under Assessment Measures, as a suggested, but not required, method to assess functioning.

Section II: diagnostic criteria and codes

Neurodevelopmental disorders

• "Mental retardation" has a new name: "intellectual disability (intellectual developmental disorder)".
• Speech or language disorders are now called communication disorders—which include language disorder (formerly expressive language disorder and mixed receptive-expressive language disorder), speech sound disorder (formerly phonological disorder), childhood-onset fluency disorder (stuttering), and a new condition characterized by impaired social verbal and nonverbal communication called social (pragmatic) communication disorder.
• Autism spectrum disorder incorporates Asperger disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS)—see Diagnosis of Asperger syndrome § DSM-5 changes.
• A new sub-category, motor disorders, encompasses developmental coordination disorder, stereotypic movement disorder, and the tic disorders including Tourette syndrome.

Schizophrenia spectrum and other psychotic disorders

• All subtypes of schizophrenia were removed from the DSM-5 (paranoid, disorganized, catatonic, undifferentiated, and residual).
• A major mood episode is required for schizoaffective disorder (for a majority of the disorder's duration after criterion A [related to delusions, hallucinations, disorganized speech or behavior, and negative symptoms such as avolition] is met).
• Criteria for delusional disorder changed, and it is no longer separate from shared delusional disorder.
• Catatonia in all contexts requires 3 of a total of 12 symptoms. Catatonia may be a specifier for depressive, bipolar, and psychotic disorders; part of another medical condition; or of another specified diagnosis.

Bipolar and related disorders

• New specifier "with mixed features" can be applied to bipolar I disorder, bipolar II disorder, bipolar disorder NED (not elsewhere defined, previously called "NOS", not otherwise specified) and MDD.
• Allows other specified bipolar and related disorder for particular conditions.
• Anxiety symptoms are a specifier (called "anxious distress") added to bipolar disorder and to depressive disorders (but are not part of the bipolar diagnostic criteria).

Depressive disorders

• The bereavement exclusion in DSM-IV was removed from depressive disorders in DSM-5.
• New disruptive mood dysregulation disorder (DMDD) for children up to age 18 years.
• Premenstrual dysphoric disorder moved from an appendix for further study, and became a disorder.
• Specifiers were added for mixed symptoms and for anxiety, along with guidance to physicians for suicidality.
• The term dysthymia now also would be called persistent depressive disorder.

Anxiety disorders

• For the various forms of phobias and anxiety disorders, DSM-5 removes the requirement that the subject (formerly, over 18 years old) "must recognize that their fear and anxiety are excessive or unreasonable". Also, the duration of at least 6 months now applies to everyone (not only to children).
• Panic attack became a specifier for all DSM-5 disorders.
• Panic disorder and agoraphobia became two separate disorders.
• Specific types of phobias became specifiers but are otherwise unchanged.
• The generalized specifier for social anxiety disorder (formerly, social phobia) changed in favor of a performance only (i.e., public speaking or performance) specifier.
• Separation anxiety disorder and selective mutism are now classified as anxiety disorders (rather than disorders of early onset).

Obsessive-compulsive and related disorders

• A new chapter on obsessive-compulsive and related disorders includes four new disorders: excoriation (skin-picking) disorder, hoarding disorder, substance-/medication-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition.
• Trichotillomania (hair-pulling disorder) moved from "impulse-control disorders not elsewhere classified" in DSM-IV, to an obsessive-compulsive disorder in DSM-5.
• A specifier was expanded (and added to body dysmorphic disorder and hoarding disorder) to allow for good or fair insight, poor insight, and "absent insight/delusional" (i.e., complete conviction that obsessive-compulsive disorder beliefs are true).
• Criteria were added to body dysmorphic disorder to describe repetitive behaviors or mental acts that may arise with perceived defects or flaws in physical appearance.
• The DSM-IV specifier “with obsessive-compulsive symptoms” moved from anxiety disorders to this new category for obsessive-compulsive and related disorders.
• There are two new diagnoses: other specified obsessive-compulsive and related disorder, which can include body-focused repetitive behavior disorder (behaviors like nail biting, lip biting, and cheek chewing, other than hair pulling and skin picking) or obsessional jealousy; and unspecified obsessive-compulsive and related disorder.

Trauma- and stressor-related disorders

• Post traumatic stress disorder (PTSD) is now included in a new section titled "Trauma- and Stressor-Related Disorders."
• The PTSD diagnostic clusters were reorganized and expanded from a total of three clusters to four based on the results of confirmatory factor analytic research conducted since the publication of DSM-IV.
• Separate criteria were added for children six years old or younger.
• For the diagnosis of acute stress disorder and PTSD, the stressor criteria (Criterion A1 in DSM-IV) was modified to some extent. The requirement for specific subjective emotional reactions (Criterion A2 in DSM-IV) was eliminated because it lacked empirical support for its utility and predictive validity. Previously certain groups, such as military personnel involved in combat, law enforcement officers and other first responders, did not meet criterion A2 in DSM-IV because their training prepared them to not react emotionally to traumatic events.
• Two new disorders that were formerly subtypes were named: reactive attachment disorder and disinhibited social engagement disorder.
• Adjustment disorders were moved to this new section and reconceptualized as stress-response syndromes. DSM-IV subtypes for depressed mood, anxious symptoms, and disturbed conduct are unchanged.

Dissociative disorders

• Depersonalization disorder is now called depersonalization/derealization disorder.
• Dissociative fugue became a specifier for dissociative amnesia.
• The criteria for dissociative identity disorder were expanded to include "possession-form phenomena and functional neurological symptoms". It is made clear that "transitions in identity may be observable by others or self-reported". Criterion B was also modified for people who experience gaps in recall of everyday events (not only trauma).

Somatic symptom and related disorders

• Somatoform disorders are now called somatic symptom and related disorders.
• Patients that present with chronic pain can now be diagnosed with the mental illness somatic symptom disorder with predominant pain; or psychological factors that affect other medical conditions; or with an adjustment disorder.
• Somatization disorder and undifferentiated somatoform disorder were combined to become somatic symptom disorder, a diagnosis which no longer requires a specific number of somatic symptoms.
• Somatic symptom and related disorders are defined by positive symptoms, and the use of medically unexplained symptoms is minimized, except in the cases of conversion disorder and pseudocyesis (false pregnancy).
• A new diagnosis is psychological factors affecting other medical conditions. This was formerly found in the DSM-IV chapter "Other Conditions That May Be a Focus of Clinical Attention".
• Criteria for conversion disorder (functional neurological symptom disorder) were changed.

Feeding and eating disorders

• Criteria for pica and rumination disorder were changed and can now refer to people of any age.
• Binge eating disorder graduated from DSM-IV's "Appendix B -- Criteria Sets and Axes Provided for Further Study" into a proper diagnosis.
• Requirements for bulimia nervosa and binge eating disorder were changed from "at least twice weekly for 6 months to at least once weekly over the last 3 months".
• The criteria for anorexia nervosa were changed; there is no longer a requirement of amenorrhea.
• "Feeding disorder of infancy or early childhood", a rarely used diagnosis in DSM-IV, was renamed to avoidant/restrictive food intake disorder, and criteria were expanded.

Elimination disorders

• No significant changes.
• Disorders in this chapter were previously classified under disorders usually first diagnosed in infancy, childhood, or adolescence in DSM-IV. Now it is an independent classification in DSM 5.

Sleep–wake disorders

• "Sleep disorders related to another mental disorder, and sleep disorders related to a general medical condition" were deleted.
• Primary insomnia became insomnia disorder, and narcolepsy is separate from other hypersomnolence.
• There are now three breathing-related sleep disorders: obstructive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation.
• Circadian rhythm sleep–wake disorders were expanded to include advanced sleep phase syndrome, irregular sleep–wake type, and non-24-hour sleep–wake type. Jet lag was removed.
• Rapid eye movement sleep behavior disorder and restless legs syndrome are each a disorder, instead of both being listed under "dyssomnia not otherwise specified" in DSM-IV.

Sexual dysfunctions

• DSM-5 has sex-specific sexual dysfunctions.
• For females, sexual desire and arousal disorders are combined into female sexual interest/arousal disorder.
• Sexual dysfunctions (except substance-/medication-induced sexual dysfunction) now require a duration of approximately 6 months and more exact severity criteria.
• A new diagnosis is genito-pelvic pain/penetration disorder which combines vaginismus and dyspareunia from DSM-IV.
• Sexual aversion disorder was deleted.
• Subtypes for all disorders include only "lifelong versus acquired" and "generalized versus situational" (one subtype was deleted from DSM-IV).
• Two subtypes were deleted: "sexual dysfunction due to a general medical condition" and "due to psychological versus combined factors".

Gender dysphoria

• DSM-IV gender identity disorder is similar to, but not the same as, gender dysphoria in DSM-5. Separate criteria for children, adolescents and adults that are appropriate for varying developmental states are added.
• Subtypes of gender identity disorder based on sexual orientation were deleted.
• Among other wording changes, criterion A and criterion B (cross-gender identification, and aversion toward one's gender) were combined. Along with these changes comes the creation of a separate gender dysphoria in children as well as one for adults and adolescents. The grouping has been moved out of the sexual disorders category and into its own. The name change was made in part due to stigmatization of the term "disorder" and the relatively common use of "gender dysphoria" in the GID literature and among specialists in the area. The creation of a specific diagnosis for children reflects the lesser ability of children to have insight into what they are experiencing and ability to express it in the event that they have insight.

Disruptive, impulse-control, and conduct disorders

Some of these disorders were formerly part of the chapter on early diagnosis, oppositional defiant disorder; conduct disorder; and disruptive behavior disorder not otherwise specified became other specified and unspecified disruptive disorder, impulse-control disorder, and conduct disorders. Intermittent explosive disorder, pyromania, and kleptomania moved to this chapter from the DSM-IV chapter "Impulse-Control Disorders Not Otherwise Specified".

• Antisocial personality disorder is listed here and in the chapter on personality disorders (but ADHD is listed under neurodevelopmental disorders).
• Symptoms for oppositional defiant disorder are of three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness. The conduct disorder exclusion is deleted. The criteria were also changed with a note on frequency requirements and a measure of severity.
• Criteria for conduct disorder are unchanged for the most part from DSM-IV. A specifier was added for people with limited "prosocial emotion", showing callous and unemotional traits.
• People over the disorder's minimum age of 6 may be diagnosed with intermittent explosive disorder without outbursts of physical aggression. Criteria were added for frequency and to specify "impulsive and/or anger based in nature, and must cause marked distress, cause impairment in occupational or interpersonal functioning, or be associated with negative financial or legal consequences".

Substance-related and addictive disorders

• Gambling disorder and tobacco use disorder are new.
• Substance abuse and substance dependence from DSM-IV-TR have been combined into single substance use disorders specific to each substance of abuse within a new "addictions and related disorders" category. "Recurrent legal problems" was deleted and "craving or a strong desire or urge to use a substance" was added to the criteria. The threshold of the number of criteria that must be met was changed and severity from mild to severe is based on the number of criteria endorsed. Criteria for cannabis and caffeine withdrawal were added. New specifiers were added for early and sustained remission along with new specifiers for "in a controlled environment" and "on maintenance therapy".

There are no more polysubstance diagnoses in DSM-5; the substance(s) must be specified.

Neurocognitive disorders

• Dementia and amnestic disorder became major or mild neurocognitive disorder (major NCD, or mild NCD). DSM-5 has a new list of neurocognitive domains. "New separate criteria are now presented" for major or mild NCD due to various conditions. Substance/medication-induced NCD and unspecified NCD are new diagnoses.

Personality disorders

• Personality disorder (PD) previously belonged to a different axis than almost all other disorders, but is now in one axis with all mental and other medical diagnoses. However, the same ten types of personality disorder are retained.
• There is a call for the DSM-5 to provide relevant clinical information that is empirically based to conceptualize personality as well as psychopathology in personalities. The issue(s) of heterogeneity of a PD is problematic as well. For example, when determining the criteria for a PD it is possible for two individuals with the same diagnosis to have completely different symptoms that would not necessarily overlap. There is also concern as to which model is better for the DSM - the diagnostic model favored by psychiatrists or the dimensional model that is favored by psychologists. The diagnostic approach/model is one that follows the diagnostic approach of traditional medicine, is more convenient to use in clinical settings, however, it does not capture the intricacies of normal or abnormal personality. The dimensional approach/model is better at showing varied degrees of personality; it places emphasis on the continuum between normal and abnormal, and abnormal as something beyond a threshold whether in unipolar or bipolar cases.

Paraphilic disorders

• New specifiers "in a controlled environment" and "in remission" were added to criteria for all paraphilic disorders.
• A distinction is made between paraphilic behaviors, or paraphilias, and paraphilic disorders. All criteria sets were changed to add the word disorder to all of the paraphilias, for example, pedophilic disorder is listed instead of pedophilia. There is no change in the basic diagnostic structure since DSM-III-R; however, people now must meet both qualitative (criterion A) and negative consequences (criterion B) criteria to be diagnosed with a paraphilic disorder. Otherwise they have a paraphilia (and no diagnosis).

Section III: emerging measures and models

Alternative DSM-5 model for personality disorders

An alternative hybrid dimensional-categorical model for personality disorders is included to stimulate further research on this modified classification system.

Conditions for further study

These conditions and criteria are set forth to encourage future research and are not meant for clinical use.

• Attenuated psychosis syndrome
• Depressive episodes with short-duration hypomania
• Persistent complex bereavement disorder
• Caffeine use disorder
• Internet gaming disorder
• Neurobehavioral disorder associated with prenatal alcohol exposure
• Suicidal behavior disorder
• Non-suicidal self-injury

Development

In 1999, a DSM-5 Research Planning Conference, sponsored jointly by APA and the National Institute of Mental Health (NIMH), was held to set the research priorities. Research Planning Work Groups produced "white papers" on the research needed to inform and shape the DSM-5 and the resulting work and recommendations were reported in an APA monograph and peer-reviewed literature. There were six workgroups, each focusing on a broad topic: Nomenclature, Neuroscience and Genetics, Developmental Issues and Diagnosis, Personality and Relational Disorders, Mental Disorders and Disability, and Cross-Cultural Issues. Three additional white papers were also due by 2004 concerning gender issues, diagnostic issues in the geriatric population, and mental disorders in infants and young children. The white papers have been followed by a series of conferences to produce recommendations relating to specific disorders and issues, with attendance limited to 25 invited researchers.

On July 23, 2007, the APA announced the task force that would oversee the development of DSM-5. The DSM-5 Task Force consisted of 27 members, including a chair and vice chair, who collectively represent research scientists from psychiatry and other disciplines, clinical care providers, and consumer and family advocates. Scientists working on the revision of the DSM had a broad range of experience and interests. The APA Board of Trustees required that all task force nominees disclose any competing interests or potentially conflicting relationships with entities that have an interest in psychiatric diagnoses and treatments as a precondition to appointment to the task force. The APA made all task force members' disclosures available during the announcement of the task force. Several individuals were ruled ineligible for task force appointments due to their competing interests.

The DSM-5 field trials included test-retest reliability which involved different clinicians doing independent evaluations of the same patient—a common approach to the study of diagnostic reliability.

About 68% of DSM-5 task-force members and 56% of panel members reported having ties to the pharmaceutical industry, such as holding stock in pharmaceutical companies, serving as consultants to industry, or serving on company boards.

Revisions and updates

Beginning with the fifth edition, it is intended that diagnostic guideline revisions will be added incrementally. The DSM-5 is identified with Arabic rather than Roman numerals, marking a change in how future updates will be created. Incremental updates will be identified with decimals (DSM-5.1, DSM-5.2, etc.), until a new edition is written. The change reflects the intent of the APA to respond more quickly when a preponderance of research supports a specific change in the manual. The research base of mental disorders is evolving at different rates for different disorders.

Criticism

General

Robert Spitzer, the head of the DSM-III task force, publicly criticized the APA for mandating that DSM-5 task force members sign a nondisclosure agreement, effectively conducting the whole process in secret: "When I first heard about this agreement, I just went bonkers. Transparency is necessary if the document is to have credibility, and, in time, you're going to have people complaining all over the place that they didn't have the opportunity to challenge anything." Allen Frances, chair of the DSM-IV task force, expressed a similar concern.

Although the APA has since instituted a disclosure policy for DSM-5 task force members, many still believe the association has not gone far enough in its efforts to be transparent and to protect against industry influence. In a 2009 Point/Counterpoint article, Lisa Cosgrove, PhD and Harold J. Bursztajn, MD noted that "the fact that 70% of the task force members have reported direct industry ties—an increase of almost 14% over the percentage of DSM-IV task force members who had industry ties—shows that disclosure policies alone, especially those that rely on an honor system, are not enough and that more specific safeguards are needed".

David Kupfer, chair of the DSM-5 task force, and Darrel A. Regier, MD, MPH, vice chair of the task force, whose industry ties are disclosed with those of the task force, countered that "collaborative relationships among government, academia, and industry are vital to the current and future development of pharmacological treatments for mental disorders". They asserted that the development of DSM-5 is the "most inclusive and transparent developmental process in the 60-year history of DSM". The developments to this new version can be viewed on the APA website. Public input was requested for the first time in the history of the manual. During periods of public comment, members of the public could sign up at the DSM-5 website and provide feedback on the various proposed changes.

In June 2009, Allen Frances issued strongly worded criticisms of the processes leading to DSM-5 and the risk of "serious, subtle, (...) ubiquitous" and "dangerous" unintended consequences such as new "false 'epidemics'". He writes that "the work on DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology" and is concerned about the task force's "inexplicably closed and secretive process". His and Spitzer's concerns about the contract that the APA drew up for consultants to sign, agreeing not to discuss drafts of the fifth edition beyond the task force and committees, have also been aired and debated.

The appointment, in May 2008, of two of the taskforce members, Kenneth Zucker and Ray Blanchard, led to an internet petition to remove them. According to MSNBC, "The petition accuses Zucker of having engaged in 'junk science' and promoting 'hurtful theories' during his career, especially advocating the idea that children who are unambiguously male or female anatomically, but seem confused about their gender identity, can be treated by encouraging gender expression in line with their anatomy." According to The Gay City News, "Dr. Ray Blanchard, a psychiatry professor at the University of Toronto, is deemed offensive for his theories that some types of transsexuality are paraphilias, or sexual urges. In this model, transsexuality is not an essential aspect of the individual, but a misdirected sexual impulse." Blanchard responded, "Naturally, it's very disappointing to me there seems to be so much misinformation about me on the Internet. [They didn't distort] my views, they completely reversed my views." Zucker "rejects the junk-science charge, saying there 'has to be an empirical basis to modify anything' in the DSM. As for hurting people, 'in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.'"

In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that brought thousands into the public debate about the DSM. Approximately 13,000 individuals and mental health professionals signed a petition in support of the letter. Thirteen other American Psychological Association divisions endorsed the petition. In a November 2011 article about the debate in the San Francisco Chronicle, Robbins notes that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences. In 2012, a footnote was added to the draft text which explains the distinction between grief and depression.

The DSM-5 has been criticized for purportedly saying nothing about the biological underpinnings of mental disorders. A book-long appraisal of the DSM-5, with contributions from philosophers, historians and anthropologists, was published in 2015.

The financial association of DSM-5 panel members with industry continues to be a concern for financial conflict of interest. Of the DSM-5 task force members, 69% report having ties to the pharmaceutical industry, an increase from the 57% of DSM-IV task force members.

A 2015 essay from an Australian university criticized the DSM-5 for having poor cultural diversity, stating that recent work done in cognitive sciences and cognitive anthropology is still only accepting western psychology as the norm.

However, DSM-5 does now include a section on how to conduct a ‘cultural formulation interview’. Published in 2013, the cultural formulation interview gives information. about how a persons cultural identity may be affecting expression of signs and symptoms. This helps clinicians to make a much more valid diagnosis for disorders subject to significant cultural variation.

Borderline personality disorder controversy

In 2003, the Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigned to change the name and designation of borderline personality disorder in DSM-5. The paper How Advocacy is Bringing BPD into the Light reported that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma." Instead, it proposed the name "emotional regulation disorder" or "emotional dysregulation disorder." There was also discussion about changing borderline personality disorder, an Axis II diagnosis (personality disorders and mental retardation), to an Axis I diagnosis (clinical disorders).

The TARA-APD recommendations do not appear to have affected the American Psychiatric Association, the publisher of the DSM. As noted above, the DSM-5 does not employ a multi-axial diagnostic scheme, therefore the distinction between Axis I and II disorders no longer exists in the DSM nosology. The name, the diagnostic criteria for, and description of, borderline personality disorder remain largely unchanged from DSM-IV-TR.

British Psychological Society response

The British Psychological Society stated in its June 2011 response to DSM-5 draft versions, that it had "more concerns than plaudits". It criticized proposed diagnoses as "clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements... not value-free, but rather reflect[ing] current normative social expectations", noting doubts over the reliability, validity, and value of existing criteria, that personality disorders were not normed on the general population, and that "not otherwise specified" categories covered a "huge" 30% of all personality disorders.

It also expressed a major concern that "clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences... which demand helping responses, but which do not reflect illnesses so much as normal individual variation".

The Society suggested as its primary specific recommendation, a change from using "diagnostic frameworks" to a description based on an individual's specific experienced problems, and that mental disorders are better explored as part of a spectrum shared with normality:

[We recommend] a revision of the way mental distress is thought about, starting with recognition of the overwhelming evidence that it is on a spectrum with 'normal' experience, and that psychosocial factors such as poverty, unemployment and trauma are the most strongly-evidenced causal factors. Rather than applying preordained diagnostic categories to clinical populations, we believe that any classification system should begin from the bottom up – starting with specific experiences, problems or 'symptoms' or 'complaints'... We would like to see the base unit of measurement as specific problems (e.g. hearing voices, feelings of anxiety etc.)? These would be more helpful too in terms of epidemiology. While some people find a name or a diagnostic label helpful, our contention is that this helpfulness results from a knowledge that their problems are recognised (in both senses of the word) understood, validated, explained (and explicable) and have some relief. Clients often, unfortunately, find that diagnosis offers only a spurious promise of such benefits. Since – for example – two people with a diagnosis of 'schizophrenia' or 'personality disorder' may possess no two symptoms in common, it is difficult to see what communicative benefit is served by using these diagnoses. We believe that a description of a person's real problems would suffice. Moncrieff and others have shown that diagnostic labels are less useful than a description of a person's problems for predicting treatment response, so again diagnoses seem positively unhelpful compared to the alternatives. - British Psychological Society June 2011 response

National Institute of Mental Health

National Institute of Mental Health director Thomas R. Insel, MD, wrote in an April 29, 2013 blog post about the DSM-5:

The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a "Bible" for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been "reliability" – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity ... Patients with mental disorders deserve better.

Insel also discussed an NIMH effort to develop a new classification system, Research Domain Criteria (RDoC), currently for research purposes only. Insel's post sparked a flurry of reaction, some of which might be termed sensationalistic, with headlines such as "Goodbye to the DSM-V", "Federal institute for mental health abandons controversial 'bible' of psychiatry", "National Institute of Mental Health abandoning the DSM", and "Psychiatry divided as mental health 'bible' denounced". Other responses provided a more nuanced analysis of the NIMH Director's post.

In May 2013, Insel, on behalf of NIMH, issued a joint statement with Jeffrey A. Lieberman, MD, president of the American Psychiatric Association, that emphasized that DSM-5 "... represents the best information currently available for clinical diagnosis of mental disorders. Patients, families, and insurers can be confident that effective treatments are available and that the DSM is the key resource for delivering the best available care. The National Institute of Mental Health (NIMH) has not changed its position on DSM-5." Insel and Lieberman say that DSM-5 and RDoC "represent complementary, not competing, frameworks" for characterizing diseases and disorders. However, epistemologists of psychiatry tend to see the RDoC project as a putative revolutionary system that in the long run will try to replace the DSM, its expected early effect being a liberalization of the research criteria, with an increasing number of research centers adopting the RDoC definitions.

Biological immortality

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Not to be confused with immortalised cell line.

Biological immortality (sometimes referred to as bio-indefinite mortality) is a state in which the rate of mortality from senescence is stable or decreasing, thus decoupling it from chronological age. Various unicellular and multicellular species, including some vertebrates, achieve this state either throughout their existence or after living long enough. A biologically immortal living being can still die from means other than senescence, such as through injury, disease, or lack of available resources.

This definition of immortality has been challenged in the Handbook of the Biology of Aging, because the increase in rate of mortality as a function of chronological age may be negligible at extremely old ages, an idea referred to as the late-life mortality plateau. The rate of mortality may cease to increase in old age, but in most cases that rate is typically very high.

The term is also used by biologists to describe cells that are not subject to the Hayflick limit on how many times they can divide.

Cell lines

Biologists chose the word "immortal" to designate cells that are not subject to the Hayflick limit, the point at which cells can no longer divide due to DNA damage or shortened telomeres. Prior to Leonard Hayflick's theory, Alexis Carrel hypothesized that all normal somatic cells were immortal.

The term "immortalization" was first applied to cancer cells that expressed the telomere-lengthening enzyme telomerase, and thereby avoided apoptosis—i.e. cell death caused by intracellular mechanisms. Among the most commonly used cell lines are HeLa and Jurkat, both of which are immortalized cancer cell lines. HeLa cells originated from a sample of cervical cancer taken from Henrietta Lacks in 1951. These cells have been and still are widely used in biological research such as creation of the polio vaccine, sex hormone steroid research, and cell metabolism. Embryonic stem cells and germ cells have also been described as immortal.

Immortal cell lines of cancer cells can be created by induction of oncogenes or loss of tumor suppressor genes. One way to induce immortality is through viral-mediated induction of the large T‑antigen, commonly introduced through simian virus 40 (SV-40).

Organisms

According to the Animal Aging and Longevity Database, the list of animals with negligible aging (along with estimated longevity in the wild) includes:

• Blanding's turtle (Emydoidea blandingii) – 77 years
• Olm (Proteus anguinus) – 102 years
• Eastern box turtle (Terrapene carolina) – 138 years
• Red sea urchin (Strongylocentrotus franciscanus) – 200 years
• Rougheye rockfish (Sebastes aleutianus) – 205 years
• Ocean quahog clam (Arctica islandica) – 507 years

In 2018, scientists working for Calico, a company owned by Alphabet, published a paper in the journal eLife which presents possible evidence that Heterocephalus glaber (Naked mole rat) do not face increased mortality risk due to aging.

Bacteria and some yeast

Many unicellular organisms age: as time passes, they divide more slowly and ultimately die. Asymmetrically dividing bacteria and yeast also age. However, symmetrically dividing bacteria and yeast can be biologically immortal under ideal growing conditions. In these conditions, when a cell splits symmetrically to produce two daughter cells, the process of cell division can restore the cell to a youthful state. However, if the parent asymmetrically buds off a daughter only the daughter is reset to the youthful state—the parent isn't restored and will go on to age and die. In a similar manner stem cells and gametes can be regarded as "immortal".

Hydra

Hydra

Hydras are a genus of the Cnidaria phylum. All cnidarians can regenerate, allowing them to recover from injury and to reproduce asexually. Hydras are simple, freshwater animals possessing radial symmetry and contain post-mitotic cells(cells that will never go divide again) only in the extremities.

All hydra cells continually divide. It has been suggested that hydras do not undergo senescence, and, as such, are biologically immortal. In a four-year study, 3 cohorts of hydra did not show an increase in mortality with age. It is possible that these animals live much longer, considering that they reach maturity in 5 to 10 days. However, this does not explain how hydras are consequently able to maintain telomere lengths.

Jellyfish

Turritopsis dohrnii, or Turritopsis nutricula, is a small (5 millimeters (0.20 in)) species of jellyfish that uses transdifferentiation to replenish cells after sexual reproduction. This cycle can repeat indefinitely, potentially rendering it biologically immortal. This organism originated in the Caribbean sea, but has now spread around the world. Similar cases include hydrozoan Laodicea undulata and scyphozoan Aurelia sp.1.

Lobsters

Research suggests that lobsters may not slow down, weaken, or lose fertility with age, and that older lobsters may be more fertile than younger lobsters. This does not however make them immortal in the traditional sense, as they are significantly more likely to die at a shell moult the older they get (as detailed below).

Their longevity may be due to telomerase, an enzyme that repairs long repetitive sections of DNA sequences at the ends of chromosomes, referred to as telomeres. Telomerase is expressed by most vertebrates during embryonic stages but is generally absent from adult stages of life. However, unlike vertebrates, lobsters express telomerase as adults through most tissue, which has been suggested to be related to their longevity. Contrary to popular belief, lobsters are not immortal. Lobsters grow by moulting which requires a lot of energy, and the larger the shell the more energy is required. Eventually, the lobster will die from exhaustion during a moult. Older lobsters are also known to stop moulting, which means that the shell will eventually become damaged, infected, or fall apart and they die. The European lobster has an average life span of 31 years for males and 54 years for females.

Planarian flatworms

Polycelis felina, a freshwater planarian

Planarian flatworms have both sexually and asexually reproducing types. Studies on genus Schmidtea mediterranea suggest these planarians appear to regenerate (i.e. heal) indefinitely, and asexual individuals have an "apparently limitless [telomere] regenerative capacity fueled by a population of highly proliferative adult stem cells". "Both asexual and sexual animals display age-related decline in telomere length; however, asexual animals are able to maintain telomere lengths somatically (i.e. during reproduction by fission or when regeneration is induced by amputation), whereas sexual animals restore telomeres by extension during sexual reproduction or during embryogenesis like other sexual species. Homeostatic telomerase activity observed in both asexual and sexual animals is not sufficient to maintain telomere length, whereas the increased activity in regenerating asexuals is sufficient to renew telomere length... "

For sexually reproducing planaria: "the lifespan of individual planarian can be as long as 3 years, likely due to the ability of neoblasts to constantly replace aging cells". Whereas for asexually reproducing planaria: "individual animals in clonal lines of some planarian species replicating by fission have been maintained for over 15 years".

Attempts to engineer biological immortality in humans

Although the premise that biological aging can be halted or reversed by foreseeable technology remains controversial, research into developing possible therapeutic interventions is underway. Among the principal drivers of international collaboration in such research is the SENS Research Foundation, a non-profit organization that advocates a number of what it claims are plausible research pathways that might lead to engineered negligible senescence in humans.

In 2015, Elizabeth Parrish, CEO of BioViva, treated herself using gene therapy with the goal of not just halting, but reversing aging. This effort was widely criticized.

For several decades, researchers have also pursued various forms of suspended animation as a means by which to indefinitely extend mammalian lifespan. Some scientists have voiced support for the feasibility of the cryopreservation of humans, known as cryonics. Cryonics is predicated on the concept that some people considered clinically dead by today's medico-legal standards are not actually dead according to information-theoretic death and can, in principle, be resuscitated given sufficient technological advances. The goal of current cryonics procedures is tissue vitrification, a technique first used to reversibly cryopreserve a viable whole organ in 2005.

Similar proposals involving suspended animation include chemical brain preservation. The non-profit Brain Preservation Foundation offers a cash prize valued at over $100,000 for demonstrations of techniques that would allow for high-fidelity, long-term storage of a mammalian brain.

In 2016, scientists at the Buck Institute for Research on Aging and the Mayo Clinic employed genetic and pharmacological approaches to ablate pro-aging senescent cells, extending healthy lifespan of mice by over 25%. The startup Unity Biotechnology is further developing this strategy in human clinical trials.

In early 2017, Harvard scientists headed by biologist David Sinclair announced they have tested a metabolic precursor that increases NAD+ levels in mice and have successfully reversed the cellular aging process and can protect the DNA from future damage. "The old mouse and young mouse cells are indistinguishable", Sinclair said. Human trials were planned to begin shortly in what the team expect is 6 months at Brigham and Women's Hospital, in Boston.

In a September 2019 article, a group of scientists reported successfully reversing the epigenetic aging in humans.

In November, 2019, the first telomere-lengthening gene therapy clinical trial has started, which aims to reverse aging by at least 20 years. This trial was criticised as being dangerous and unethical due to the usage of genetically modified viruses from an unknown source.

In April, 2020, a group of researchers made a breakthrough in halting the premature aging of cells due to the telomere disease, called dyskeratosis congenita. While directly this is for curing diseases, in the longterm, it can be a base for longevity treatments.

In May, 2020, there was a successful experiment to reduce aging in mice by an average of 54%, with the transfusion of young blood plasma.

In November, 2020, a group of scientists at Tel Aviv University and the Shamir Medical Center have been successfully reversed ageing in human blood cells by applying hyperbaric oxygen treatment (HBOT) on a group of patients for 90 days. The patients' blood cells became 25 years younger, their telomeres were lengthened by 38% and the number of senescent cells decreased by 37%.  Some physicians have voiced their concerns that this therapy can cause health problems and some are skeptical about that ageing could be reversed by just one treatment, that we do not know if removing senescent cells will reverse ageing and some warned, that lengthened telomeres are also present in cancer diseases and advised great caution.

In December, 2020 a group of scientists proposed a new possible cause for ageing: the accumulation of epigenetic noise. They have successfully reprogrammed a group of nerve cells which resulted in restoring the epigenetic information and vision in mice.

Criticism

To achieve the more limited goal of halting the increase in mortality rate with age, a solution must be found to the fact that any intervention to remove senescent cells that creates competition among cells will increase age-related mortality from cancer.

Immortalism and immortality as a movement

In 2012 in Russia, and then in the United States, Israel, and the Netherlands, pro-immortality transhumanist political parties were launched. They aim to provide political support to anti-aging and radical life extension research and technologies and want to ensure the fastest possible—and at the same time, the least disruptive—societal transition to radical life extension, life without aging, and ultimately, immortality. They aim to make it possible to provide access to such technologies to the majority of people alive today.

Future medicine, life extension and "swallowing the doctor"

Future advances in nanomedicine could give rise to life extension through the repair of many processes thought to be responsible for aging. K. Eric Drexler, one of the founders of nanotechnology, postulated cell repair devices, including ones operating within cells and using as yet hypothetical molecular machines, in his 1986 book Engines of Creation. Raymond Kurzweil, a futurist and transhumanist, stated in his 2005 book The Singularity Is Near that he believes that advanced medical nanorobotics could completely remedy the effects of aging by 2030. According to Richard Feynman, it was his former graduate student and collaborator Albert Hibbs who originally suggested to him in around 1959 the idea of a medical use for Feynman's theoretical micromachines. Hibbs suggested that certain repair machines might one day be reduced in size to the point that it would, in theory, be possible to (as Feynman put it) "swallow the doctor". The idea was incorporated into Feynman's 1959 essay There's Plenty of Room at the Bottom.

Metal toxicity

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Metal_toxicity 

Metal toxicity or metal poisoning is the toxic effect of certain metals in certain forms and doses on life. Some metals are toxic when they form poisonous soluble compounds. Certain metals have no biological role, i.e. are not essential minerals, or are toxic when in a certain form. In the case of lead, any measurable amount may have negative health effects. Often heavy metals are thought as synonymous, but lighter metals may also be toxic in certain circumstances, such as beryllium and lithium. Not all heavy metals are particularly toxic, and some are essential, such as iron. The definition may also include trace elements when in abnormally high doses may be toxic. An option for treatment of metal poisoning may be chelation therapy, which is a technique which involves the administration of chelation agents to remove metals from the body.

Toxic metals sometimes imitate the action of an essential element in the body, interfering with the metabolic process resulting in illness. Many metals, particularly heavy metals are toxic, but some heavy metals are essential, and some, such as bismuth, have a low toxicity. Most often the definition of toxic metals includes at least thallium, cadmium, manganese, lead, mercury and the radioactive metals. Metalloids (arsenic, polonium) may be included in the definition. Radioactive metals have both radiological toxicity and chemical toxicity. Metals in an oxidation state abnormal to the body may also become toxic: chromium(III) is an essential trace element, but chromium(VI) is a carcinogen.

Toxicity is a function of solubility. Insoluble compounds as well as the metallic forms often exhibit negligible toxicity. The toxicity of any metal depends on its ligands. In some cases, organometallic forms, such as methylmercury and tetraethyl lead, can be extremely toxic. In other cases, organometallic derivatives are less toxic such as the cobaltocenium cation.

Decontamination for toxic metals is different from organic toxins: because toxic metals are elements, they cannot be destroyed. Toxic metals may be made insoluble or collected, possibly by the aid of chelating agents, or through bioremediation. Alternatively, they can be diluted into a sufficiently large reservoir, such as the sea, because immediate toxicity is a function of concentration rather than amount.

Toxic metals can bioaccumulate in the body and in the food chain. Therefore, a common characteristic of toxic metals is the chronic nature of their toxicity. This is particularly notable with radioactive heavy metals such as radium, which imitates calcium to the point of being incorporated into human bone, although similar health implications are found in lead or mercury poisoning.

Testing for poisoning

People are continually exposed to metals in the environment. Medical tests can detect metals often, but this is to be expected and alone is not evidence that a person is poisoned. Metal screening tests should not be used unless there is reason to believe that a person has had excessive exposure to metals. People should seek medical testing for poisoning only if they are concerned for a particular reason, and physicians should consider a patient's history and physical examination before conducting tests to detect metals.

Treatment for poisoning

Chelation therapy is a medical procedure that involves the administration of chelating agents to remove heavy metals from the body. Chelating agents are molecules that have multiple electron-donating groups, which can form stable coordination complexes with metal ions. Complexation prevents the metal ions from reacting with molecules in the body, and enable them to be dissolved in blood and eliminated in urine. It should only be used in people who have a diagnosis of metal intoxication. That diagnosis should be validated with tests done in appropriate biological samples.

Chelation therapy is administered under very careful medical supervision due to various inherent risks. Even when the therapy is administered properly, the chelation drugs can have significant side effects. Chelation administered inappropriately can cause neurodevelopmental toxicity, increase risk of developing cancer, and cause death; chelation also removes essential metal elements and requires measures to prevent their loss.

Specific types of poisoning

Aluminium phosphide poisoning

Aluminium has no known biological role and its classification into toxic metals is controversial.

Acute aluminium phosphide poisoning (AAlPP) is a large, though under-reported, problem in the Indian subcontinent. Aluminium phosphide (AlP), which is readily available as a fumigant for stored cereal grains, sold under various brand names such as QuickPhos and Celphos, is highly toxic, especially when consumed from a freshly opened container. Death results from profound shock, myocarditis and multi-organ failure. Aluminium phosphide has a fatal dose of between 0.15 and 0.5 grams (0.0053 and 0.0176 oz). It has been reported to be the most common cause of suicidal death in North India. The very high toxicity of aluminium phosphide is attributed to the phosphine content and is not related to aluminium. Calcium phosphide and zinc phosphide are similar poisons.

Arsenic poisoning

Arsenic poisoning is a medical condition caused by elevated levels of arsenic in the body. The dominant basis of arsenic poisoning is from ground water that naturally contains high concentrations of arsenic. A 2007 study found that over 137 million people in more than 70 countries are probably affected by arsenic poisoning from drinking water.

Beryllium poisoning

Beryllium poisoning is illness resulting from the toxic effect of beryllium in its elemental form or in various chemical compounds. The toxicity of beryllium depends upon the duration, intensity and frequency of exposure (features of dose), as well as the form of beryllium and the route of exposure (i.e. inhalation, dermal, ingestion). According to the International Agency for Research on Cancer (IARC), beryllium and beryllium compounds are Category 1 carcinogens; they are carcinogenic to both animals and humans.

Cadmium poisoning

Cadmium is an extremely toxic metal commonly found in industrial workplaces. Due to its low permissible exposure limit, overexposures may occur even in situations where trace quantities of cadmium are found. Cadmium is used extensively in electroplating, although the nature of the operation does not generally lead to overexposures. Cadmium is also found in some industrial paints and may represent a hazard when sprayed. Operations involving removal of cadmium paints by scraping or blasting may pose a significant hazard. Cadmium is also present in the manufacturing of some types of batteries. Exposures to cadmium are addressed in specific standards for the general industry, shipyard employment, construction industry, and the agricultural industry.

Copper toxicity

Copper toxicity, also called copperiedus, refers to the consequences of an excess of copper in the body. Copperiedus can occur from eating acid foods cooked in uncoated copper cookware, or from exposure to excess copper in drinking water, as a side-effect of estrogen birth control pills, or other environmental sources. It can also result from the genetic condition Wilson's disease.

Iron poisoning

Iron poisoning is an iron overload caused by a large excess of iron intake and usually refers to an acute overload rather than a gradual one. The term has been primarily associated with young children who consumed large quantities of iron supplement pills, which resemble sweets and are widely used, including by pregnant women—see overnutrition (approximately 3 grams is lethal for a 2 year old). Targeted packaging restrictions in the US for supplement containers with over 250 mg elemental iron have existed since 1978, and recommendations for unit packaging have reduced the several iron poisoning fatalities per year to almost nil since 1998. No known cases of iron poisoning have been identified that are associated with iron mining.

Lead poisoning

Lead poisoning is a medical condition in humans and other vertebrates caused by increased levels of the heavy metal lead in the body. Lead interferes with a variety of body processes and is toxic to many organs and tissues including the heart, bones, intestines, kidneys, and reproductive and nervous systems. It interferes with the development of the nervous system and is therefore particularly toxic to children, causing potentially permanent learning and behavior disorders. Symptoms include abdominal cramping, constipation, tremors, mood changes, infertility, anemia, and toxic psychosis.

Lithium poisoning

Lithium is used in some medications, specifically to treat bipolar disorder. The level of "sufficient" medication is thought by many physicians to be close to toxic tolerance for kidney function. Therefore, the patient is often monitored for this purpose.

Manganese poisoning, or manganism

Manganism or manganese poisoning is a toxic condition resulting from chronic exposure to manganese and first identified in 1837 by James Couper.

Mercury poisoning

Mercury poisoning is a disease caused by exposure to mercury or its compounds. Mercury (chemical symbol Hg) is a heavy metal occurring in several forms, all of which can produce toxic effects in high enough doses. Its zero oxidation state Hg⁰ exists as vapor or as liquid metal, its mercurous state Hg₂²⁺ exists as inorganic salts, and its mercuric state Hg²⁺ may form either inorganic salts or organomercury compounds; the three groups vary in effects. Toxic effects include damage to the brain, kidney, and lungs. Mercury poisoning can result in several diseases, including acrodynia (pink disease), Hunter-Russell syndrome, and Minamata disease.

Symptoms typically include sensory impairment (vision, hearing, speech), disturbed sensation and a lack of coordination. The type and degree of symptoms exhibited depend upon the individual toxin, the dose, and the method and duration of exposure.

Silver poisoning (Argyria)

A 92-year-old Caucasian man (right) with pigmentary changes had used nose drops containing silver for many years. His skin biopsy showed silver deposits in the dermis, confirming the diagnosis of generalized argyria.

Argyria or argyrosis is a condition caused by inappropriate exposure to chemical compounds of the element silver, or to silver dust. The most dramatic symptom of argyria is that the skin turns blue or bluish-grey. It may take the form of generalized argyria or local argyria. Generalized argyria affects large areas over much of the visible surface of the body. Local argyria shows in limited regions of the body, such as patches of skin, parts of the mucous membrane or the conjunctiva.

Thallium poisoning

Thallium and its compounds are often highly toxic. Contact with skin is dangerous, and adequate ventilation should be provided when melting this metal. Many thallium(I) compounds are highly soluble in water and are readily absorbed through the skin. Exposure to them should not exceed 0.1 mg per m² of skin in an 8-hour time-weighted average (40-hour work week). Thallium is a suspected human carcinogen.

Tin poisoning

Tin poisoning refers to the toxic effects of tin and its compounds. Cases of poisoning from tin metal, its oxides, and its salts are "almost unknown"; on the other hand certain organotin compounds are almost as toxic as cyanide.

Zinc toxicity

Even though zinc is an essential requirement for a healthy body, excess zinc can be harmful, and cause zinc toxicity. Such toxicity levels have been seen to occur at ingestion of greater than 225 mg of Zinc. Excessive absorption of zinc can suppress copper and iron absorption. The free zinc ion in solution is highly toxic to bacteria, plants, invertebrates, and even vertebrate fish.

Society and culture

It is difficult to differentiate the effects of low level metal poisoning from the environment with other kinds of environmental harms, including nonmetal pollution. Generally, increased exposure to heavy metals in the environment increases risk of developing cancer.

Without a diagnosis of metal toxicity and outside of evidence-based medicine, but perhaps because of worry about metal toxicity, some people seek chelation therapy to treat autism, cardiovascular disease, Alzheimer's disease, or any sort of neurodegeneration. Chelation therapy does not improve outcomes for those diseases.