Psychiatrists rewriting the mental health bible

SAN FRANCISCO — Is the compulsion to hoard things a mental disorder? How about the practice of eating excessively at night?

And what of Internet addiction: Should it be diagnosed and treated?

As the clock ticks toward the release of the most influential of mental health textbooks, psychiatrists are asking themselves thousands of complex and sometimes controversial questions.

The answers will determine how Americans' mental health is assessed, diagnosed and treated.

Over the next 18 months, psychiatrists will hammer out a draft of the fifth edition of the American Psychiatric Assn.'s Diagnostic and Statistical Manual of Mental Disorders, more commonly called DSM-V. Nowhere have the discussions been more heated, the ramifications most vividly foretold, than here at the organization's annual meeting.

Some psychiatrists warn that the tome runs the risk of medicalizing the normal range of human behaviors; others vehemently argue that it must be broad enough to guide treatment of those who need it.

But all agree that the so-called bible of psychiatry is expected to be considerably more nuanced and science-based than the last edition, DSM-IV, published in 1994.

Brain imaging and other technologies, plus new knowledge on biological and genetic causes of many disorders, have almost guaranteed significant alterations in how many mental afflictions are described.

"There are no constraints on the degree of change," said Dr. David J. Kupfer, chairman of the DSM-V task force and a psychiatrist at the University of Pittsburgh's Western Psychiatric Institute and Clinic.

The book will describe disorders in more detail, acknowledge variations that haven't been viewed as part of "classic" illness and explain how conditions differ based on age, race, gender, culture and physical health, Kupfer said.

Planning on the text began almost a decade ago, and leaders delivered a progress report to their colleagues last week. They emphasized that the book, slated for publication in 2012, should better reflect the lives and complexities of real people, not simply the most severe cases or most cut-and-dried diagnoses.

Critics of the current edition -- and there are many -- say that it allows for diagnosis only after a dramatic threshold has been reached.

"We are really hoping we'll be able to improve things," Kupfer said. "And that will help us do a better job of taking care of our patients."