Revision to the bible of psychiatry, DSM, could introduce new mental disorders

Revision to the bible of psychiatry, DSM, could introduce new mental disorders



By Rob Stein
Washington Post Staff Writer
Wednesday, February 10, 2010

Children who throw too many tantrums could be diagnosed with "temper dysregulation with dysphoria." Teenagers who are particularly eccentric might be candidates for treatment for "psychosis risk syndrome." Men who are just way too interested in sex face being labeled as suffering from "hypersexual disorder."

These are among dozens of proposals being unveiled Wednesday by the American Psychiatric Association in the first complete revision since 1994 of the Diagnostic and Statistical Manual of Mental Disorders, or "DSM" -- the massive tome that has served as the bible for modern psychiatry for more than half a century.

The product of more than a decade of work by hundreds of experts, the proposed revisions are designed to bring the best scientific evidence to bear on psychiatric diagnoses and could have far-reaching implications, including determining who gets diagnosed as mentally ill, who should get powerful psychotropic drugs, and whether and how much insurance companies will pay for care.

"It not only determines how mental disorders are diagnosed, it can impact how people see themselves and how we see each other," said Alan Schatzberg, the association's president. "It influences how research is conducted as well as what is researched. . . . It affects legal matters, industry and government programs."

The proposals will be debated in an intense process over the next two years, with potentially billions of dollars at stake for pharmaceutical companies, insurance companies, government health plans, doctors, researchers and patient advocacy groups.

But perhaps more important, the outcome will help shape which emotions, behaviors, thoughts and personality traits society considers part of the natural spectrum of the human persona and which are considered pathological, requiring treatment and possibly even criminal punishment.

Even before being made public, the proposed changes have been the subject of sometimes bitter debate over whether the process was based on solid scientific evidence and was adequately shielded from influence by the pharmaceutical industry, and whether some critics were driven by financial interests in maintaining the old diagnostic criteria.

Supporters argue that the revisions would make diagnoses more accurate, creating more useful and precise definitions and sometimes reducing the number of psychiatric labels. For example, "autistic disorder" and "Asperger's disorder" would be replaced with a new, single category called "autism spectrum disorders." Critics, however, fear the new diagnoses could unnecessarily stigmatize many people and lead to the unnecessary use of psychiatric medications that can sometimes produce serious side effects.

"By massively pathologizing people under these categories, you tend to put them on an automatic path to medication, even if they are experiencing normal distress," said Jerome C. Wakefield, a professor of social work and psychiatry at New York University.

After being posted on the Internet, which of the proposed changes become final will be determined by a public comment period that will last until April 20, studies to validate some of the changes, further review, and votes by the association's Board of Trustees and Assembly. A final version is expected to be released by May 2013.

"We're mindful of the concern that we don't want to overdiagnose," Schatzberg told reporters during a telephone briefing Tuesday. "We want to, in fact, get an accurate assessment of what the degree of psychopathology might be in the culture."

Among the concerns are proposals to create "risk syndromes" in the hopes that early diagnosis and treatment will stave off the full-blown conditions. For example, the proposals would create a "psychosis risk syndrome" for people who have mild symptoms found in psychotic disorders, such as "excessive suspicion, delusions and disorganized speech or behavior."

"There will be adolescents who are a little odd and have funny ideas, and this will label them as pre-psychotic," said Robert Spitzer, a professor of psychiatry at Columbia University, who has been one of the most vocal critics of the DSM revision process.

Similarly, a proposal to create a new condition for people at risk for dementia could cause unnecessary anxiety, treatment and other harms, critics said.

"These people will never get long-term-care insurance if they have that on their chart," said Michael B. First, a professor of psychiatry at Columbia University.

William Carpenter of the University of Maryland, who chaired the working group that made the risk syndrome recommendation, acknowledged those concerns but said that experts decided that the potential benefits of early intervention warranted the move.

Others expressed concern about the proposals to create new conditions such as "temper dysregulation with dysphoria," or TDD. Supporters say it is intended to counter a huge increase in the number children being treated for bipolar disorder by creating a more specific diagnosis, though critics argued that it would only compound the problem of overtreatment.

"They are close to treating the children like guinea pigs. I think that's appalling and outrageous," said Christopher Lane, author of "Shyness: How Normal Behavior Became a Sickness." "The APA should be moving to prevent such controversial practices, not encouraging them, as it is doing here."

In addition to classifying the symptoms of grief that many people experience after the death of a loved one as "depression," the proposals include adding "binge eating" and "gambling addiction" as bona fide psychiatric conditions; they also raise the possibility of making "Internet addiction" a future diagnosis. Some critics questioned the proposal to create a "hypersexual disorder."

"How many people with just healthy sex drives will be given that label?" First said.

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