16 May 2013

Experts debate what's 'normal'

The latest guidebook of mental disorders is causing much controversy with many saying everyday anxiety or tantrums are now classified as mental disorders.

The new version of the world's most widely used psychiatric guide to mental disorders says grief soon after a loved one's death now can be considered major depression. Extreme childhood temper tantrums get a fancy name. And certain forgetful moments for the ageing are called "mild neurocognitive disorder".

Those changes are just some of the reasons prominent critics say the American Psychiatric Association is out of control, turning common problems into mental illnesses in a trend they say will just make the "pop-a-pill" culture worse.

Says a former leader of the group: "Normal needs to be saved from powerful forces trying to convince us that we are all sick."

Diagnosing mental problems

At issue is the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, widely known as the DSM-5. The DSM has long been considered the authoritative source for diagnosing mental problems.

The psychiatric association formally introduces the nearly 1 000-page revised version this weekend in San Francisco. It's the manual's first major update in nearly 20 years, and a backlash has taken shape in recent weeks:

  • Two new books by mental health experts, "Saving Normal" and "The Book of Woe," say the manual has lost credibility.
  • A British psychologists' group is criticising the DSM-5, calling for a "paradigm shift" away from viewing mental problems as a disease. An organisation of German therapists also attacked the new guide.
  • The head of the US National Institute of Mental Health, Dr Thomas Insel, said the book lacks scientific validity.

The manual's release comes at a time of increased scrutiny of health care costs and concern about drug companies' influence over doctors. Critics point to a landscape in which TV ads describe symptoms for mental disorders and promote certain drugs to treat them.

Many of the 31 task force members involved in developing the revised guidebook have had financial ties to makers of psychiatric drugs, including consulting fees, research grants or stock. Group leaders dismiss that criticism and emphasise they agreed not to collect more than $10,000 (R92 563) in industry money in the calendar year preceding publication of the manual.

"Way too much treatment is given to the normal 'worried well' who are harmed by it; far too little help is available for those who are really ill and desperately need it," Dr Allen Frances writes in "Saving Normal." He is a retired Duke University professor who led the psychiatric group's task force that worked on the previous guide.

Bad eating habits and mental disorders

He says the new version adds new diagnoses "that would turn everyday anxiety, eccentricity, forgetting and bad eating habits into mental disorders."

Previous revisions were also loudly criticized, but the latest one comes at a time of soaring diagnoses of illnesses listed in the manual — including autism, attention deficit disorder and bipolar disorder — and billions of dollars spent each year on psychiatric drugs.

The group's 34 000 members are psychiatrists — medical doctors who specialize in treating mental illness. Unlike psychologists and other therapists without medical degrees, they can prescribe medication. While there has long been rivalry between the two groups, the DSM-5 revisions have stoked the tensions.

The most contentious changes include these:

  • Diagnosing as major depression the extreme sadness, weight loss, fatigue and trouble sleeping some people experience after a loved one's death. Major depression is typically treated with antidepressants.
  • Calling frequent, extreme temper tantrums "disruptive mood dysregulation disorder," a new diagnosis. The psychiatric association says the label is meant to apply to youth who in the past might have been misdiagnosed as having bipolar disorder. Critics say it turns normal tantrums into mental illness.
  • Diagnosing mental decline that goes a bit beyond normal aging as "mild neurocognitive disorder." Affected people may find it takes more effort to pay bills or manage their medications. Critics of the term say it will stigmatize so-called "senior moments."
  • Calling excessive thoughts or feelings about pain or other discomfort "somatic symptom disorder," something that could affect the healthy as well as cancer patients. Critics say the term turns normal reactions to a disease into mental illness.
  • Adding binge eating as a new category for overeating that occurs at least once a week for at least three months. It could apply to people who sometimes gulp down a pint of ice cream when they're alone and then feel guilty about it.
  • Removing Asperger's syndrome as a separate diagnosis and putting it under the umbrella term "autism spectrum disorder."

Accurate diagnoses and treatment

Dr David Kupfer, chairman of the task force that oversaw the DSM-5, said the changes are based on solid research and will help make sure people get accurate diagnoses and treatment.

Dr Jeffrey Lieberman, the association's incoming president, said challenging the handbook's credibility "is completely unwarranted." He said the book takes into account the most up-to-date scientific knowledge.

But Insel, the government mental health agency chief, wrote in a recent blog posting that the guidebook is no better than a dictionary-like list of labels and definitions.

He told The Associated Press he favours a very different approach to diagnosis that is based more on biological information, similar to how doctors diagnose heart disease or problems with other organs.

Yet there's scant hard evidence pinpointing what goes wrong in the brain when someone develops mental illness. Insel's agency two years ago began a research project to create a new way to diagnose mental illness, using brain imaging, genetics and other evolving scientific evidence. That project will take years.

Advocacy groups have threatened protests and boycotts at this week's meeting of the psychiatric association.

"The psychiatric industry, allied with Big Pharma, have massively misled the public," the Occupy Psychiatry group contends. Organisers include lawyer Jim Gottstein, who has long fought against overuse of psychiatric drugs.

The new manual "will drastically expand psychiatric diagnosis, mislabel millions of people as mentally ill, and cause unnecessary treatment with medication," says the website for the Committee to Boycott the DSM-5, organized by New York social worker Jack Carney.

Committee member Courtney Fitzpatrick, whose 9-year-old son died seven years ago while hospitalised for a blood vessel disease, said she has joined support groups for grieving parents "and by no means are we mentally ill because we are sad about our kids that have died."


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