Revising Book on Disorders of the Mind

http://www.nytimes.com/2010/02/10/health/10psych.html
February 10, 2010
Revising Book on Disorders of the Mind
By BENEDICT CAREY
Far fewer children would get a diagnosis of bipolar disorder. “Binge eating disorder” and “hypersexuality” might become part of the everyday language. And the way many mental disorders are diagnosed and treated would be sharply revised.
These are a few of the changes proposed on Tuesday by doctors charged with revising psychiatry’s encyclopedia of mental disorders, the guidebook that largely determines where society draws the line between normal and not normal, between eccentricity and illness, between self-indulgence and self-destruction — and, by extension, when and how patients should be treated.
The eagerly awaited revisions — to be published, if adopted, in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, due in 2013 — would be the first in a decade.
For months they have been the subject of intense speculation and lobbying by advocacy groups, and some proposed changes have already been widely discussed — including folding the diagnosis of Asperger’s syndrome into a broader category, autism spectrum disorder.
But others, including a proposed alternative for bipolar disorder in many children, were unveiled on Tuesday. Experts said the recommendations, posted online at DSM5.org for public comment, could bring rapid change in several areas.
“Anything you put in that book, any little change you make, has huge implications not only for psychiatry but for pharmaceutical marketing, research, for the legal system, for who’s considered to be normal or not, for who’s considered disabled,” said Dr. Michael First, a professor of psychiatry at Columbia University who edited the fourth edition of the manual but is not involved in the fifth.
“And it has huge implications for stigma,” Dr. First continued, “because the more disorders you put in, the more people get labels, and the higher the risk that some get inappropriate treatment.”
One significant change would be adding a childhood disorder called temper dysregulation disorder with dysphoria, a recommendation that grew out of recent findings that many wildly aggressive, irritable children who have been given a diagnosis of bipolar disorder do not have it.
The misdiagnosis led many children to be given powerful antipsychotic drugs, which have serious side effects, including metabolic changes.
“The treatment of bipolar disorder is meds first, meds second and meds third,” said Dr. Jack McClellan, a psychiatrist at the University of Washington who is not working on the manual. “Whereas if these kids have a behavior disorder, then behavioral treatment should be considered the primary treatment.”
Some diagnoses of bipolar disorder have been in children as young as 2, and there have been widespread reports that doctors promoting the diagnosis received consulting and speaking fees from the makers of the drugs.
In a conference call on Tuesday, Dr. David Shaffer, a child psychiatrist at Columbia, said he and his colleagues on the panel working on the manual “wanted to come up with a diagnosis that captures the behavioral disturbance and mood upset, and hope the people contemplating a diagnosis of bipolar for these patients would think again.”
Experts gave the American Psychiatric Association, which publishes the manual, predictably mixed reviews. Some were relieved that the task force working on the manual — which includes neurologists and psychologists as well as psychiatrists — had revised the previous version rather than trying to rewrite it.
Others criticized the authors, saying many diagnoses in the manual would still lack a rigorous scientific basis.
The good news, said Edward Shorter, a historian of psychiatry who has been critical of the manual, is that most patients will be spared the confusion of a changed diagnosis. But “the bad news,” he added, “is that the scientific status of the main diseases in previous editions of the D.S.M. — the keystones of the vault of psychiatry — is fragile.”
To more completely characterize all patients, the authors propose using measures of severity, from mild to severe, and ratings of symptoms, like anxiety, that are found as often with personality disorders as with depression.
“In the current version of the manual, people either meet the threshold by having a certain number of symptoms, or they don’t,” said Dr. Darrel A. Regier, the psychiatric association’s research director and, with Dr. David J. Kupfer of the University of Pittsburgh, the co-chairman of the task force. “But often that doesn’t fit reality. Someone with schizophrenia might have symptoms of insomnia, of anxiety; these aren’t the diagnostic criteria for schizophrenia, but they affect the patient’s life, and we’d like to have a standard way of measuring them.”
In a conference call on Tuesday, Dr. Regier, Dr. Kupfer and several other members of the task force outlined their favored revisions. The task force favored making semantic changes that some psychiatrists have long argued for, trading the term “mental retardation” for “intellectual disability,” for instance, and “substance abuse” for “addiction.”
One of the most controversial proposals was to identify “risk syndromes,” that is, a risk of developing a disorder like schizophrenia or dementia. Studies of teenagers identified as at high risk of developing psychosis, for instance, find that 70 percent or more in fact do not come down with the disorder.
“I completely understand the idea of trying to catch something early,” Dr. First said, “but there’s a huge potential that many unusual, semi-deviant, creative kids could fall under this umbrella and carry this label for the rest of their lives.”
Dr. William T. Carpenter, a psychiatrist at the University of Maryland and part of the group proposing the idea, said it needed more testing. “Concerns about stigma and excessive treatment must be there,” he said. “But keep in mind that these are individuals seeking help, who have distress, and the question is, What’s wrong with them?”
The panel proposed adding several disorders with a high likelihood of entering the pop vernacular. One, a new description of sex addiction, is “hypersexuality,” which, in part, is when “a great deal of time is consumed by sexual fantasies and urges; and in planning for and engaging in sexual behavior.”
Another is “binge eating disorder,” defined as at least one binge a week for three months — eating platefuls of food, fast, and to the point of discomfort — accompanied by severe guilt and plunges in mood.
“This is not the normative overeating that we all do, by any means,” said Dr. B. Timothy Walsh, a psychiatrist at Columbia and the New York State Psychiatric Institute who is working on the manual. “It involves much more loss of control, more distress, deeper feelings of guilt and unhappiness.”




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