Caffeine is the most widely used behaviorally active drug in the world and is present in many different types of beverages, foods, energy aids, medications, and dietary supplements. Because caffeine ingestion is often integrated into social customs and daily rituals, some caffeine consumers may be unaware of their physical dependence on caffeine. It is estimated that more than 85% of adults and children in the US regularly consume caffeine.
For anyone who has ever tried to quit drinking their favorite caffeinated beverage (my guilty pleasure is fountain soda), you know the associated pains. Headache, fatigue, difficulty concentrating, moodiness, irritability, etc.
The new DSM-5 classifies caffeine withdrawal as a potential disorder (page 506-507 if you don’t believe me). Symptoms usually begin 12-24 hours after the last caffeine dose and peak after 1-2 days of abstinence. Caffeine withdrawal symptoms typically last for 2 to 9 days, with the possibility of withdrawal headaches occurring for up to 21 days.
Gradual reduction in caffeine is suggested to reduce the incidence and severity of withdrawal symptoms.
Grief after the loss of a loved one may be considered major depression, according to the new psychiatric manual.
After years of controversy, the latest version of the “psychiatric bible” — the Diagnostic and Statistical Manual of Mental Disorders — has been released.
The DSM-5 (fifth edition)’s introduction, over the weekend at the American Psychiatric Association’s annual meeting, marks “the end of more than a decade’s journey in revising the criteria for the diagnosis and classification of mental disorders,” the association says on the DSM-5 website.
The manual includes the criteria used by mental health professionals to diagnose patients. It’s also used by insurance companies, schools and other agencies responsible for covering and creating special provisions for individuals with developmental or mental disorders.
The overhaul — the first for the DSM since 1994 — has not come without opposition from activists, some grass-roots organizations and even the National Institute of Mental Health, which last month said it was launching a project aimed at laying the foundation for a new classification system and would be “re-orienting its research away from DSM categories.”
Here are five ways the DSM changes may affect you:
Bereavement or depression?
Previously, clinicians were advised against diagnosing major depression in people within two months after the death of a loved one: the “bereavement exclusion.”
The DSM-5 removes the exclusion, a move the psychiatric association says “helps prevent major depression from being overlooked and facilitates the possibility of appropriate treatment including therapy or other interventions.”
Research has shown that for some people, the death of a loved one can precipitate major depression — much like other stressors such as losing a job, the association says on the DSM-5 website. But “bereavement is the only life event and stressor specifically excluded from a diagnoses of major depression” in previous manuals.
Binge eating is officially an eating disorder
Binge eating was approved as its own category of eating disorder in the DSM-5. It’s defined as “recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control.”
According to the association, the move is aimed at “increasing awareness of the substantial differences between binge eating disorder and the common phenomenon of overeating. While overeating is a challenge for many Americans, recurrent binge eating is much less common, far more severe, and is associated with significant physical and psychological problems.”
Binge drinkers may be diagnosed as mild alcoholics
Prior DSM editions included “alcohol abuse,” along with the more serious “dependence.” However, the DSM-5 will make “alcohol use disorder” a single condition.
“The field of substance abuse and addiction has witnessed an explosion in important research in the past two decades,” said Dr. David Kupfer, chairman of the DSM-5 Task Force, in a February statement. The changes “reflect the best science in the field and provide new clarity in how to diagnose these disorders.”
The proposal to group Asperger’s and other developmental conditions together generated a flurry of comments and concerns. In 2010, when the change was proposed, the Asperger’s Association of New England, a nonprofit organization with more than 3,000 members, wrote a letter to the American Psychiatric Association emphasizing that Asperger’s should remain separate.
But “the revised diagnosis represents a new, more accurate, and medically and scientifically useful way of diagnosing individuals with autism-related disorders,” the national group says on the DSM-5 website.
The work group that recommended the change “believes a single umbrella disorder will improve the diagnoses of ASD without limiting the sensitivity of the criteria, or substantially changing the number of children being diagnosed.”
In a statement on its website Tuesday, the New England association assures its members, “regardless of your diagnosis or label, we will continue to provide a gathering place where members of the Asperger’s community can connect to one another.”
The DSM-5 eliminates the term “gender identity disorder,” which mental health specialists, along with lesbian, gay, bisexual and transgender activists, had considered stigmatizing. It refers to “gender dysphoria,” which focuses attention only on those who feel distressed by their gender identity.
“I think it’s a significant change,” Jack Drescher, a member of the psychiatric association group that recommended the change, said late last year. “It’s clinically defensible, but it reduces the amount of stigma and harm that existed before.”
Homosexuality was removed from the DSM in 1973, a move he believes changed global views.
Some LGBT activists applauded the change, while others have questioned whether it goes far enough.
The controversial revision to psychiatrists’ “bible” of diagnostic criteria has finally arrived. The American Psychiatric Association released its fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or dubbed simply as the “DSM-5.”
The manual’s release was coincided with the APA’s annual meeting that kicked off May 18 in San Francisco.
The first major revision to the manual in almost two decades, the new DSM has been met by controversy since reports of proposed changes started to crop up last March.
Doctors often utilize the DSM to diagnose mental health disorders in patients that meet a specific set of criteria.
Among the major changes that garnered the most controversy was dropping Asperger’s syndrome, child disintegrative disorder and pervasive developmental disorder not otherwise specified (PDD), and included them under the blanket diagnosis of autism spectrum disorder.
Revisions were also made to diagnostic criteria for mental health disorders including schizophrenia, bipolar disorder, dissociative identity disorder and depressive disorders.
For example, in the last version of the manual, the 1994 DSM-IV, there was was an exclusion criterion for a major depressive episode that was applied to people with symptoms of depression lasting less than 2 months following the death of a loved one. The DSM-5 removed this after the APA realized since the last version that grief can last up to two years, and bereavement can be a severe psychological stressor that triggers depression, rather than an exception.
Besides worrying some mental health advocates over concerns changes in their diagnosis would affect their abilities to get treatment for state funding, the manual’s release also pitted the government’s National Institute of Mental Health (NIMH) and the American Psychiatric Association (APA),
NIMH director Thomas Insel wrote in a statement in early May that the NIMH felt the proposed definitions for psychiatric disorders were too broad and ignore smaller disorders that were lumped in with a larger diagnosis.
“The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever,” he wrote.
The government agency said it would use a different classification system, the Research Domain Criteria (RDoC) project, instead for its studies.
The NIH and APA released a joint statement on May 13, saying that “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.” But, the statement also said, “The National Institute of Mental Health (NIMH) has not changed its position on DSM-5.”
One vocal critic, Dr. Allen Frances, who co-authored the DSM-IV, told CBS This Morning on Thursday that we are over-treating people in this country who are “basically well” and are “shamefully neglecting” people with mental disorders who are really sick, including one million people in prison with psychiatric disorders. The new manual, he said, is too loose for its diagnoses.
He said the average diagnosis is being given by a primary care doctor in a seven minute visit.
“People who are basically normal are getting all kinds of medicine that they don’t need that makes them worse and it is a terrible drain on the economy,” Frances said.
“I’m very curious to see what happens because as you know there’s kind of this tension between the DSM and some of the new NIMH initiatives,” Dr. James Murrough, an assistant professor of psychiatry and neuroscience at Mount Sinai Hospital in New York City, told CBSNews.com Murrough was not involved in the new DSM, but will be presenting research at the APA meeting this weekend.
He said by now, some psychiatrists had hoped the new DSM would contain more information about scientific tests or scans for psychologists or psychiatrists to help aid their diagnoses. But, he added the new version doesn’t appear to look very different from the last one.
“I think everyone is kind of disappointed that we don’t have that yet,” he said.
More information about the DSM-5 can be found on the APA’s website.
Yesterday, the board of trustees of the American Psychiatric Association (APA) approved a set of updates, revisions and changes to the reference manual used to diagnose mental disorders. The revision of the manual, called the Diagnostic and Statistical Manual of Mental Disorders and abbreviated as the DSM, is the first significant update in nearly two decades.
Disorders that will be in the new DSM-5 — but only in Section 3, a category of disorders needing further research — include: Attenuated psychosis syndrome, Internet use gaming disorder, Non-suicidal self-injury, and Suicidal behavioral disorder. Section 3 disorders generally won’t be reimbursed by insurance companies for treatment, since they are still undergoing research and revision to their criteria.
So here’s a list of the major updates…
Overall Changes to the DSM
According to the American Psychiatric Association’s statement, there are two major changes to the overall DSM — the dumping of the multiaxial system, and rearranging the chapter order of disorders. Most clinicians only paid attention to Axis I and II, so it’s no surprise the Axis system was never a big hit. The current chapter order has always been a bit of a mystery to most clinicians, so it’s good to know there’s some thought going into the new order of chapters.
DSM-5’s 20 chapters will be restructured based on disorders’ apparent relatedness to one another, as reflected by similarities in disorders’ underlying vulnerabilities and symptom characteristics.
The changes will align DSM-5 with the World Health Organization’s (WHO) International Classification of Diseases, eleventh edition (ICD-11) and are expected to facilitate improved communication and common use of diagnoses across disorders within chapters.
Removal of multiaxial system:
DSM-5 will move to a nonaxial documentation of diagnosis, combining the former Axes I, II, and III, with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).
Autistic disorders will undergo a reshuffling and renaming:
“[Autism] criteria will incorporate several diagnoses from DSM-IV including autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder (not otherwise specified) into the diagnosis of autism spectrum disorder for DSM-5 to help more accurately and consistently diagnose children with autism,” according to an APA statement Saturday.
The rest of this update comes from the APA’s news release on the changes:
Binge eating disorderwill be moved from DSM-IV’s Appendix B: Criteria Sets and Axes Provided for Further Study to DSM-5 Section 2. The change is intended to better represent the symptoms and behaviors of people with this condition.
This means binge eating disorder is now a real, recognized mental disorder.
Disruptive mood dysregulation disorder will be included in DSM-5 to diagnose children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year.
The diagnosis is intended to address concerns about potential over-diagnosis and overtreatment of bipolar disorder in children. Will children now stop being diagnosed with bipolar disorder, which has been a recurring concern among many clinicians and researchers? We will see.
Excoriation (skin-picking) disorder is new to DSM-5 and will be included in the Obsessive-Compulsive and Related Disorders chapter.
Hoarding disorder is new to DSM-5.
Its addition to DSM is supported by extensive scientific research on this disorder. This disorder will help characterize people with persistent difficulty discarding or parting with possessions, regardless of their actual value. The behavior usually has harmful effects — emotional, physical, social, financial and even legal — for a hoarder and family members.
Pedophilic disorder criteria will remain unchanged from DSM-IV, but the disorder name will be revised from pedophilia to pedophilic disorder.
DSM-5 will maintain the categorical model and criteria for the 10 personality disorders included in DSM-IV and will include the new trait-specific methodology in a separate area of Section 3 to encourage further study how this could be used to diagnose personality disorders in clinical practice.
Posttraumatic stress disorder (PTSD) will be included in a new chapter in DSM-5 on Trauma- and Stressor-Related Disorders.
DSM-5 pays more attention to the behavioral symptoms that accompany PTSD and proposes four distinct diagnostic clusters instead of three. PTSD will also be more developmentally sensitive for children and adolescents.
Removal of bereavement exclusion:
The exclusion criterion in DSM-IV applied to people experiencing depressive symptoms lasting less than two months following the death of a loved one has been removed and replaced by several notes within the text delineating the differences between grief and depression. This reflects the recognition that bereavement is a severe psychosocial stressor that can precipitate a major depressive episode beginning soon after the loss of a loved one.
Specific learning disorder broadens the DSM-IV criteria to represent distinct disorders which interfere with the acquisition and use of one or more of the following academic skills: oral language, reading, written language, or mathematics.
Substance use disorder will combine the DSM-IV categories of substance abuse and
substance dependence. In this one overarching disorder, the criteria have not only been combined, but strengthened. Previous substance abuse criteria required only one symptom while the DSM-5’s mild substance use disorder requires two to three symptoms.
The APA board of trustees also outright rejected some new disorder ideas. The following disorders won’t appear anywhere in the new DSM-5:
Parental alienation syndrome
Sensory processing disorder
Although clinicians are “treating” these concerns, the board of trustees felt like there wasn’t even enough research to consider putting them in Section 3 of the new DSM (disorders needing further research).
So there you have it. What do you think about these final decisions for the DSM-5?
The now familiar term “Asperger’s disorder” is being dropped. And abnormally bad and frequent temper tantrums will be given a scientific-sounding diagnosis called DMDD. But “dyslexia” and other learning disorders remain.
The revisions come in the first major rewrite in nearly 20 years of the diagnostic guide used by the nation’s psychiatrists. Changes were approved Saturday.
Full details of all the revisions will come next May when the American Psychiatric Association’s new diagnostic manual is published, but the impact will be huge, affecting millions of children and adults worldwide. The manual also is important for the insurance industry in deciding what treatment to pay for, and it helps schools decide how to allot special education.
This diagnostic guide “defines what constellations of symptoms” doctors recognize as mental disorders, said Dr. Mark Olfson, a Columbia University psychiatry professor. More important, he said, it “shapes who will receive what treatment. Even seemingly subtle changes to the criteria can have substantial effects on patterns of care.”
Olfson was not involved in the revision process. The changes were approved Saturday in suburban Washington, D.C., by the psychiatric association’s board of trustees.
The aim is not to expand the number of people diagnosed with mental illness, but to ensure that affected children and adults are more accurately diagnosed so they can get the most appropriate treatment, said Dr. David Kupfer. He chaired the task force in charge of revising the manual and is a psychiatry professor at the University of Pittsburgh.
One of the most hotly argued changes was how to define the various ranges of autism. Some advocates opposed the idea of dropping the specific diagnosis for Asperger’s disorder. People with that disorder often have high intelligence and vast knowledge on narrow subjects but lack social skills. Some who have the condition embrace their quirkiness and vow to continue to use the label.
And some Asperger’s families opposed any change, fearing their kids would lose a diagnosis and no longer be eligible for special services.
But the revision will not affect their education services, experts say.
The new manual adds the term “autism spectrum disorder,” which already is used by many experts in the field. Asperger’s disorder will be dropped and incorporated under that umbrella diagnosis. The new category will include kids with severe autism, who often don’t talk or interact, as well as those with milder forms.
Kelli Gibson of Battle Creek, Mich., who has four sons with various forms of autism, said Saturday she welcomes the change. Her boys all had different labels in the old diagnostic manual, including a 14-year-old with Asperger’s.
“To give it separate names never made sense to me,” Gibson said. “To me, my children all had autism.”
Three of her boys receive special education services in public school; the fourth is enrolled in a school for disabled children. The new autism diagnosis won’t affect those services, Gibson said. She also has a 3-year-old daughter without autism.
People with dyslexia also were closely watching for the new updated doctors’ guide. Many with the reading disorder did not want their diagnosis to be dropped. And it won’t be. Instead, the new manual will have a broader learning disorder category to cover several conditions including dyslexia, which causes difficulty understanding letters and recognizing written words.
The trustees on Saturday made the final decision on what proposals made the cut; recommendations came from experts in several work groups assigned to evaluate different mental illnesses.
The revised guidebook “represents a significant step forward for the field. It will improve our ability to accurately diagnose psychiatric disorders,” Dr. David Fassler, the group’s treasurer and a University of Vermont psychiatry professor, said after the vote.
The shorthand name for the new edition, the organization’s fifth revision of the Diagnostic and Statistical Manual, is DSM-5. Group leaders said specifics won’t be disclosed until the manual is published but they confirmed some changes. A 2000 edition of the manual made minor changes but the last major edition was published in 1994.
Olfson said the manual “seeks to capture the current state of knowledge of psychiatric disorders. Since 2000 … there have been important advances in our understanding of the nature of psychiatric disorders.”
Catherine Lord, an autism expert at Weill Cornell Medical College in New York who was on the psychiatric group’s autism task force, said anyone who met criteria for Asperger’s in the old manual would be included in the new diagnosis.
One reason for the change is that some states and school systems don’t provide services for children and adults with Asperger’s, or provide fewer services than those given an autism diagnosis, she said.
Autism researcher Geraldine Dawson, chief science officer for the advocacy group Autism Speaks, said small studies have suggested the new criteria will be effective. But she said it will be crucial to monitor so that children don’t lose services.
Other changes include:
— A new diagnosis for severe recurrent temper tantrums — disruptive mood dysregulation disorder. Critics say it will medicalize kids’ who have normal tantrums. Supporters say it will address concerns about too many kids being misdiagnosed with bipolar disorder and treated with powerful psychiatric drugs. Bipolar disorder involves sharp mood swings and affected children are sometimes very irritable or have explosive tantrums.
— Eliminating the term “gender identity disorder.” It has been used for children or adults who strongly believe that they were born the wrong gender. But many activists believe the condition isn’t a disorder and say calling it one is stigmatizing. The term would be replaced with “gender dysphoria,” which means emotional distress over one’s gender. Supporters equated the change with removing homosexuality as a mental illness in the diagnostic manual, which happened decades ago.
With crunch time looming for the ongoing revision of the psychiatry profession’s diagnostic manual, critics hoping to stop what they see as destructive changes are taking their campaign to the consumer media.
In early February, British psychologists and psychiatrists unhappy with proposed changes in the fifth edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders — the DSM-5, in its forthcoming incarnation — staged a successful press conference in London, which generated news coverage around the world.
Meanwhile, the most prominent U.S.-based critic of DSM-5, Allen Frances, MD — chairman of the task force that developed the fourth DSM edition in 1994 — has become a regular contributor to the popular Huffington Post website. Last week, he suggested there that the government should force the APA to abandon some of the proposed changes.
And the explosion in social media has allowed other, less well-connected mental health professionals and interested laypeople to create their own platforms for airing concerns about DSM-5 — starting websites and writing comments on others.
At least in part, the rising furor is driven by the DSM-5 revision schedule. The APA has committed to releasing the final version at its May 2013 meeting. Its internal process for ratifying it requires that it be in essentially final form this winter.
Thus, only a few months remain for critics to sway the DSM-5 leadership.
When Does Grief Become Depression?
Most of the criticism has focused on a few of the many dozens of changes that the DSM-5 working groups have proposed. These include eliminating the so-called bereavement exclusion in diagnosing major depression and adding new diagnoses for people with mild psychotic-like symptoms and problem child behaviors such as severe, repetitive tantrums.
The complaints have a common theme: that the DSM-5 will medicalize — and therefore stigmatize — normal human behaviors.
At the London press conference, for example, psychiatrist Nick Craddock, director of the Welsh National Centre for Mental Health in the U.K., argued that removing the bereavement exclusion would have such an effect.
Under DSM-IV criteria, someone who has lost a loved one can be diagnosed with major depression only if depression symptoms last longer than two months or if they include features not typical of normal grief, such as suicidal ideation.
The proposals for DSM-5 would drop this caveat, allowing for diagnosis of major depression two weeks after a loved one’s death.
According to the DSM-5 working group on depressive disorders, there is no evidence to justify an exclusion for grief but not for other stressors such as divorce, sudden physical disability, or losing one’s home or job.
Defenders of the proposal have also argued that individuals with normal grief may benefit from counseling, which may not be covered by insurance without a DSM-sanctioned diagnosis.
Craddock agreed, but countered that such individuals “did not need a label saying they had a mental illness.”
Similar complaints have been leveled at the proposed new diagnosis of attenuated psychosis syndrome. Its proponents intended it to cover people with persistent but mild hallucinatory symptoms and disturbed thinking — mild enough that the individuals recognize that they aren’t real, but serious enough to find the symptoms bothersome.
In a commentary published in the Feb. 18 issue of The Lancet, two researchers said it would be “premature” to include the syndrome in the DSM.
Paolo Fusar-Poli, MD, of King’s College London, and Alison R. Yung, PhD, of the University of Melbourne in Australia, said that, from the evidence so far, the population likely to receive the diagnosis “is heterogeneous in presentation, clinical needs, and outcome” — and thus too ill-defined without more research and additional diagnostic criteria.
‘Shrinking the Pool of Normality’
One British psychologist, referring to the DSM-5 as a whole, told the Guardian newspaper that its proposals “are likely to shrink the pool of normality to a puddle.”
They also allege that, by expanding the number of people potentially qualifying for a psychiatric diagnosis, DSM-5 will inevitably increase the number treated with drugs.
Another of the speakers at the London press conference, David Pilgrim, of the University of Central Lancashire in Preston, England, called it “hard to avoid the conclusion that DSM-5 will help the interests of the drug companies.”
Former New England Journal of Medicine editor Marcia Angell, MD, noted last year in the New York Review of Books that more than half of DSM-5 working group members had “significant industry interests.”
Frances, too, has written that the DSM-5 will be a “bonanza for the pharmaceutical industry.” But most of his criticisms, which he took public in 2009, have focused on the revision process.
He has been especially concerned with delays in the process — the APA had originally scheduled publication of DSM-5 for this May, but decided in 2009 to push it back one year — and what he believes has been a resulting rush to deliver a final product.
He has repeatedly called on the APA to abandon the revision in its current form. Recently he argued that the Obama administration’s decision to delay implementation of the ICD-10 classification system in the U.S. undercut the APA’s arguments for the May 2013 deadline for DSM-5.
DSM-5 Leaders Stand Their Ground
In a conversation with MedPage Today, APA President John Oldham, MD, and DSM-5 task force chairman David Kupfer, MD, defended their handling of the revision and argued that many of the criticisms were off-base.
For starters, Kupfer said, the proposed revisions were still open to change or abandonment. The DSM-5 will assume its near-final form in June or July, he said — meaning that the APA’s annual meeting in May would provide another forum to debate the changes.
“[The proposals] are still open to revision,” he said. “The door is still very much open.”
Oldham said he was satisfied with the process so far. “It’s an enormously long, and difficult, and challenging thing to do,” he said. “We’re not going to get it perfect. I don’t think anybody could. I don’t think any previous edition could.”
Oldham and Kupfer also argued in favor of removing the bereavement exclusion from the depression criteria.
Said Kupfer, “If patients are suffering not from normal sadness or grief, but are suffering from a severity of symptoms that constitute clinical depression, and need intervention, and they want help, that they should not be prevented from getting the appropriate care that they need because somebody tells them that, well, this is what everybody has when they have a loss.”
Oldham noted that extreme sadness can be triggered by any number of events — natural disasters, physical disability, job losses — yet the DSM-IV created an exclusion only for “bereavement.”
He also pointed out that there are “ranges of heritable risk for major depression” — suggesting that depression may in some sense be normal, yet deserving treatment nonetheless.
The DSM’s overarching purpose, Oldham said, is to enable “patients who need treatment [to] get it.”
Kupfer conceded that field trials of the revised criteria, by design, were not testing whether the changes would increase or decrease the number of people receiving a particular diagnosis. As a result, the critics’ worries won’t be refuted or confirmed until after the revisions go into effect.
“We won’t get 100% consensus on all the proposals,” Oldham said. “That would be totally unrealistic. But I personally think it’s been a thorough and careful process. We’re going to have disagreement. That’s going to happen.”
DSM-IV-TR vs. Proposed DSM-5: Comparison, Implications and Impact
Join NAADAC on February 29, 2012 from 3-4 p.m. EST and earn one continuing education credit. A revised edition of the Diagnostic and Statistical Manual of Mental Disorders will be released in May 2013. This webinar will examine the proposal and let professionals know what to prepare for.
A controversial decision to reclassify grief as a mental illness has been criticised by medical experts.
The change in classification was intended to add flexibility to how early people can be treated for depression following the death of a loved one. But it has led to worries that bereaved people will be treated with pills rather than empathy.
An editorial in influential medical journal, The Lancet, argues that grief does not require psychiatrists and that ‘legitimizing’ the treatment of grief with antidepressants ‘is not only dangerously simplistic, but also flawed.’
The unsigned lead editorial reads: ‘Grief is not an illness; it is more usefully thought of as part of being human and a normal response to the death of a loved one.’
The Lancet’s comments follow the American Psychiatric Association’s decision to add grief reactions to their list of mental illnesses in their fifth edition of the psychiatry ‘bible’, Diagnostic and Statistical Manual of Mental Disorders, (DSM-5), which is due out in 2013.
But The Lancet, along with many psychiatrists and psychologists have called for the changes to be halted – saying they would lead to a ‘tick box’ system that did not consider the wider needs of patients but labelled them as ‘mentally ill’.
They agree that in rare cases, bereavement will develop into prolonged grief or major depression that may merit medical treatment. However, they suggested that for the majority of the bereaved, ‘doctors would do better to offer time, compassion, remembrance and empathy, than pills.’
The DSM-5 proposal – which has been opposed by The Lancet’s editorial writers – would eliminate the so-called ‘grief exclusion.’
This ‘exclusion’ means that anyone who has experienced bereavement cannot be diagnosed as depressed for a certain period of time.
In a previous edition, DSM-III, that period of time was set at one year.
The DSM-IV reduced that period to two months and DSM-5 plans to reduce the period to just two weeks.
Although the proposed changes to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) would not directly affect clinical practice here, where doctors tend to use different international guidelines, experts say it would eventually influence research and thinking in the field.
Defending the change in timeframe, Dr. Kenneth S. Kendler, a member of the DSM-5 Mood Disorder Working Group, said it would allow for an earlier diagnosis but would by no means force it.
Simon Wessely, of the Institute of Psychiatry, King’s College, London, said ‘We need to be very careful before further broadening the boundaries of illness and disorder.’
‘Back in 1840 the Census of the United States included just one category for mental disorder.
‘By 1917 the American Psychiatric Association recognised 59, rising to 128 in 1959, 227 in 1980, and 347 in the last revision. Do we really need all these labels? Probably not. And there is a real danger that shyness will become social phobia, bookish kids labelled as Asperger’s and so on.’
Whereas people who are bereaved are currently given help where necessary, in future they might find themselves labelled as having a depressive disorder if their symptoms lasted longer than a certain period of time, he added.
Peter Kinderman, Professor of Clinical Psychology and Head of Institute of Psychology, University of Liverpool, said ‘It will exacerbate the problems that result from trying to fit a medical, diagnostic, system to problems that just don’t fit nicely into those boxes.
‘Perhaps most seriously, it will pathologise a wide range of problems which should never be thought of as mental illnesses. Many people who are shy, bereaved, eccentric, or have unconventional romantic lives will suddenly find themselves labelled as ‘mentally ill’.
Dr. Arthur Kleinman, a Harvard psychiatrist, social anthropologist and global health expert, says that the main problem is the lack of ‘conclusive scientific evidence to show what a normal length of bereavement is.’
According to the Lancet writers, ‘it is often not until 6 months, or the first anniversary of the death, that grieving can move into a less intense phase.’
They added that grieving is individual, shaped by age, gender, religious beliefs and the strength of the relationship with the lost loved one.
Proposed revisions to the Diagnostic and Statistical Manual of Mental Disorders (DSM), the fat text used to help identify and categorize mental illness, are not sitting well with many mental health professionals and the public.
Suggested changes to the definitions of autism spectrum disorders and depression, among others, are eliciting great concerns. And experts say there are larger concerns about the DSM as a whole.
“Almost no one likes the DSM, but no one knows what to do about it,” said University of Michigan psychiatrist Dr. Randolph Nesse.
The current round of revisions is the fifth since the DSM was originally published by the American Psychiatric Association in 1952.
Nesse and University of Cape Town psychiatrist Dr. Dan Stein combined for an article in the current issue of BMC Medicine titled “Towards a genuinely medical model for psychiatric nosology.”
The article provides a candid appraisal of the difficulty of categorizing mental disorders that the authors expect will not make a lot of their colleagues happy.
“The problem is not the DSM criteria,” Nesse said. “The problem is that the untidy nature of mental disorders is at odds with our wish for a neat, clean classification system.”
The proposed abolition of the grief exclusion, for example, in diagnosing major depression is just one example of a push to define psychiatric disorders according to their causes and brain pathology.
“A huge debate over when depression is abnormal seems likely to be resolved by removing the so-called ‘grief exclusion,’” Nesse said. “At the moment, depression is not diagnosed in the two months after loss of a loved one.
“The result of this proposed change would be that people experiencing normal grief will receive a diagnosis of major depression. Doing this would increase consistency in diagnosing depression, but at the cost of common sense. It’s clear that bereavement is not a mental disorder.”
Nesse and Stein point out that the rest of medicine recognizes many disorders that do not have specific causes.
“Conditions such as congestive heart failure can have many causes,” Nesse said. “This doesn’t bother physicians because they understand what the heart is for, and how it works to circulate blood.”
Furthermore, he said, physicians recognize symptoms such as fever and pain as useful responses, not diseases.
“These symptoms can be pathological when they’re expressed for no good reason, but before considering that possibility, physicians look carefully for some abnormality arousing such symptoms,” Nesse said. “Likewise, the utility of anxiety is recognized, but its disorders are defined by the number and intensity of symptoms, irrespective of the cause.
“It’s vital to recognize that emotions serve functions in the same way that pain, cough and fever do, and that strong negative emotions can be normal responses to challenging or anxiety-provoking situations.”
Instead of specific diseases with specific causes, many mental problems are “somewhat heterogeneous overlapping syndromes that can have multiple causes,” Nesse said.
“Most are not distinct species like birds or flowers. They are more like different plant communities, each with a typical collection of species. Distinguishing tundra from alpine meadow, arboreal forest and Sonoran desert is useful, even though the categories are not entirely homogenous and distinct.”
Internet addiction might be considered a mental illness under proposed revisions to DSM-5, the mental-health industry’s guidebook.
The DSM-5, as the new edition will be called, is scheduled to be released in May 2013, and could list “Internet addiction” among its diagnoses.
The association says it is still considering how to address non-substance-abuse addictions.
“Gambling disorder has been moved into this category and there are other addiction-like behaviorial disorders such as ‘Internet addiction’ that will be considered as potential addictions to this category as research data accumulate,” the APA says on its website.
Experts say lots of the new diagnoses are problematic – like “oppositional defiant disorder.”
“That basically means children who say ‘no’ to their parents more than a certain number of times,” said Pete Kinderman of Liverpool University’s Institute of Psychology, according to Reuters.
“On that criteria, many of us would have to say our children are mentally ill.”
People who are excessively shy could also be diagnosed as mentally ill under the new guidelines, Kinderman said.
Kids’ temper tantrums might be explained by “disruptive mood disregulation disorder,” characterized by temper outbursts that occur at least three times per week.
David Elkins, president of the American Psychological Association’s society for humanistic psychology, helped launch a petition against the new manual, yielding more than 11,000 supporters, according to ABC News.
“Our main concern is that they’ve introduced some new disorders that have never been in a DSM before that we think are not scientifically based,” he said.
“We’re not opposed to the proper use of psychiatric drugs when there’s a real diagnosis and when a child or an adult needs pharmacological interventions,” he said. “But we are concerned about the normal kids and elderly people who are going to be diagnosed with these disorders and treated with psychiatric drugs.
“We think that’s very, very dangerous.”
Dr. Allen Frances, who worked on revisions for the current manual, DSM-4, agrees that the proposed changes are irresponsible.
“You don’t want to be inventing new diagnoses until you’re sure they can be accurately made, effectively treated that the treatments are safe,” said Frances, a psychiatry professor at Duke University, according to ABC News. “None of these conditions is fulfilled in DSM-5.”
“You can’t have one professional organization, like the American Psychiatric Association, responsible for vetting something so important,” he added.
The APA hasn’t commented directly on the backlash, but said in a statement that it considers “input from all sectors of the mental health community a vital part of the process,” according to ABC News.
“We are confident that the DSM-5 will be based on the most reliable scientific and clinical data.”