How do controversial revisions in psychiatry's guidebook make you feel?

Posted: May 05, 2012

When upward of 10,000 members of the American Psychiatric Association meet here this weekend, they'll be met by protesters - there are always protesters - and tough questions about where their profession is headed and how it will define normalcy for the rest of us.

The official theme of the annual meeting, which opens Saturday at the Pennsylvania Convention Center, is integrated care, a nod to the increasingly interdisciplinary nature of medicine in the health-reform era. But many sessions will also focus on the association's highly controversial overhaul of the Diagnostic and Statistical Manual of Mental Disorders, the dominant guidebook to mental maladies and a key factor in determining insurance payments.

The current tome, the DSM-IV, was published in 1994 and updated in 2000. The book now in the works, the DSM-5 (yes, they dropped the Roman numerals), is due out by next year's APA meeting.

Supporters say the revisions incorporate more current science into the highly influential book. It also strives for diagnoses that show how seriously ill patients are.

Critics say the changes jump ahead of the science and expand what is considered mental illness. While the association tries to detect illnesses earlier and possibly prevent their most tragic symptoms, it risks calling essentially normal people mentally ill, needlessly exposing thousands to stigma and strong medicines, and handing drugmakers a bonanza.

One hot-button proposal allows grieving people to be considered depressed after two weeks of symptoms. Another addresses children who were being labeled bipolar by creating a different diagnosis: disruptive mood dysregulation disorder. Some worry that diagnoses meant to identify thinking problems in the elderly will turn normal aging into a disorder.

The University of Pennsylvania was one of 11 academic medical centers that field-tested the book's new approach. It looked at five diagnoses, including three new ones: hoarding disorder, binge-eating disorder, and mixed depression and anxiety.

In what is surely biting criticism in the mental-health world, David N. Elkins, a psychology professor emeritus at Pepperdine University, said the APA "should listen. They don't listen very well. They need to listen to the outcry and take it seriously."

The APA must have listened a little. It announced this week that it had moved the new attenuated psychosis syndrome, which attempted to identify young people likely to develop psychosis, and mixed anxiety and depression to a book section for conditions that need more research. They also tried to better differentiate normal grief from depression.

Last fall, Elkins, president of the Society for Humanistic Psychology, helped draft an open letter critiquing proposed changes. It got 13,000 signatures online, he said.

His and other groups are so miffed that they plan to write their own book. "We are calling for a summit in New York City in the summer of 2013 of all the mental-health professions," Elkins said. "We need a manual that is produced in an egalitarian way."

One of the most vocal critics is psychiatrist Allen Frances, who edited the DSM-IV. He said that overdiagnosing and overprescribing of antipsychotic drugs, particularly in children and the elderly, were already big problems. Psychiatry, he said, should be asking, "How can we put a governor on this? What DSM-5 will do, instead, is open up the flood gates."

The new approach, he said, gives "drug companies a free pass to convince everyone in the world that they have one disorder or two or three."

There's also the matter of autism. Its proposed definition is more restrictive. That has caused an outcry from autism advocates, who fear children will lose school services.

Frances thinks his group has made the current definition too broad. If fewer children with mild symptoms are diagnosed, "that's a good thing."

He also thinks the APA has too much money at stake to be objective. He says it makes $5 million to $10 million a year on sales of the manual.

The APA says it has invested $25 million in developing the new DSM over the last 12 years. It deflected a question about how much income the book generates.

David Kupfer, a University of Pittsburgh psychiatrist who heads the DSM-5 task force, said nothing was set in stone. A third six-week comment period opened Wednesday. The APA already has received close to 10,800 comments.

"We do want more public commentary," Kupfer said. "We are carefully examining this with some of our review groups. We certainly do not want to make changes for the sake of making changes."

For the record, he said, the number of diagnoses is dropping from 280 to 220.

John Oldham, the psychiatric association's president, said one of the DSM's roles has been to provide definitions that lead to better research. Mental health and illness are on a continuum with no clear lines of demarcation, but scientists need to find the earliest signs of dysfunction. "It's important for us," he said, "to be trying to understand when the right time is to intervene."

Thomas R. Insel, a psychiatrist who directs the National Institute of Mental Health, sees psychiatry heading toward what he calls "clinical neuroscience." Psychiatrists should study the brain the way cardiologists study the heart, he said.

While people assume that thinking of mental illnesses as brain disorders will lead to more medication, Insel said his agency has funded research into cognitive training, therapy that uses the brain's ability to change. It also is studying diet and family support.

"There is no biochemical imbalance that we have ever been able to demonstrate," he said. "What we think about are changes in circuitry and how the brain is processing information."

It makes sense to him to try to identify at-risk youths before they develop symptoms that can devastate their ability to work or have fulfilling relationships. The most debilitating of the mental illnesses, schizophrenia and bipolar disorder, often are diagnosed in early adulthood, but researchers are studying signs that emerge years earlier.

Critics say that lots of teens have eccentric behaviors but won't become mentally ill. This is true, Insel said, but "science entirely supports" figuring out who's going to become psychotic and preventing it. "That doesn't mean medicate earlier," he said.

The institute has embarked on its own attempt to classify mental illnesses based on what's happening in the brain rather than on symptoms.

Asked whether the association should delay rewriting the DSM until the science advances, he said, "That's a fair question. I'm not going to answer it." Then he said, "I think the DSM-IV is extremely helpful."

Mahendra Bhati, a psychiatrist who headed the Penn field trial, is confident that the new disorders his clinic tested are genuine mental illnesses. They don't necessarily need drug treatment.

But he found the new approach to personality disorders "clinically impractical."

Overall, he said, "I honestly don't think it's going to make a huge difference in how I practice psychiatry." His prescriptions, he said, are based on symptoms, not diagnoses.

On Saturday, as psychiatrists inside the convention center discuss proposed DSM changes, protesters outside plan to "Occupy the American Psychiatric Association." They'll have a "label rip," where they tear up the very diagnosis names that the psychiatrists are intent on defining.

"We'd have to be Don Quixote to think we're going to stop it at this point," David Oaks said of the DSM-5. A veteran of many such protests, Oaks, a Harvard grad who has been called schizophrenic and bipolar, is executive director of MindFreedom International and one of the event organizers. He says psychiatrists have not listened enough to their "customers," who often find peer and social support more helpful than drugs.


Contact Stacey Burling

at 215-854-4944 or sburling@phillynews.com.

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