Guidelines debated for mental disorders

Proposed new definitions could alter diagnosis

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When Brent Robbins was a boy, he said, "I was an odd kid. I was a bit of a clown." And after one of his episodes of showing off, he recalled, "my teachers demanded my parents take me to a psychiatrist."

Luckily, said the head of the psychology program at Point Park University, "they happened to take me to someone who said, 'Oh, he's a wonderful kid. He'll never quite fit in, but he's fine.' And by the time I was in college, I was flourishing and had found my niche."

Those experiences have made him wary of anyone today who wants to label an eccentric child as mentally ill, and it's one of the reasons he has become a national leader of a movement that is raising questions about the American Psychiatric Association's attempt to create an updated "bible" of mental disorders.

As a representative of the Society for Humanistic Psychology, Mr. Robbins has been instrumental in drafting a critical letter to the task force revising the Diagnostic and Statistical Manual of Mental Disorders. The letter already has attracted more than 10,000 signatures of support, most from mental health professionals.

One of his particular concerns is a proposed new diagnosis in the DSM-5 called attenuated psychosis syndrome, which says that those who experience hallucinations or delusions may be at risk of later developing a full-blown psychosis.

Some studies have shown that only about 20 percent of adolescents who exhibit these symptoms later develop schizophrenia, though, and Mr. Robbins worries that the inclusion of this diagnosis in the manual could unfairly label many teens as mentally ill and put them on a regimen of heavy-duty psychotropic drugs.

"My concern here is that a lot of people who may just be eccentric or unusual might turn out to be wonderful, gifted people. Imagine what Salvador Dali or Andy Warhol were like as adolescents. Some people might have interpreted their behavior as delusional.

"I'm very concerned that you're going to have a lot of wonderful, uniquely gifted kids who instead of being appreciated will be labeled as dysfunctional."

It's just one of many objections that have been raised about the DSM-5, which is going through its final revisions and is due to be published in the spring of 2013.

The manual revision task force is being chaired by eminent UPMC psychiatrist David Kupfer, who was not available for comment.

But other leading members of the task force stressed that none of the DSM-5 proposals is final, and that all the major diagnoses are being field tested for clarity and reliability.

On the attenuated psychosis syndrome, William Narrow, research director for the DSM-5 Task Force, said that because some adolescents who show these symptoms do go on to get full-blown schizophrenia, "formal designation of an attenuated psychosis syndrome in DSM would mean a greater likelihood that clinicians will recognize the syndrome ... and be able to follow the symptoms over time and intervene when needed."

And that intervention, Dr. Narrow stressed, might include various kinds of talk therapy or treatment with omega-3 fatty acids rather than drugs. "Because of potential long-term side effects, the current practice has generally been to withhold antipsychotic medication treatments for patients with this syndrome until a full psychotic disorder emerges," he wrote.

The other new definition that bothers Mr. Robbins is one called disruptive mood dysregulation disorder, or DMDD, described as excessive temper outbursts occurring three or more times a week in children younger than 10.

Mr. Robbins said this category serves as a substitute for the earlier diagnosis of pediatric bipolar disorder, and he fears that children who get the diagnosis also may be prescribed heavy-duty psychotropic medications.

"I think there are some kids and adults who absolutely need medications," he said, "so it would be a mistake to assume we have an anti-drug message. But realistically, if you can find any other intervention, especially for children, you want to do it because drugs are a double-edged sword, because every drug has side effects."

Darrel Regier, director of the psychiatric association's research division, said the DMDD category actually was developed because many doctors feared that too many children were inappropriately getting bipolar diagnoses.

"Some psychiatrists wondered if we needed to have a better way of describing these explosive and sometimes destructive kids who are being diagnosed with bipolar disorder but don't seem to have the family history of bipolar disorder," he said last week.

The third focus of the humanistic psychology letter is on proposed changes in the diagnosis of depression that would remove language in the current manual that excludes normal grieving over the loss of a loved one.

A new report by researchers at Columbia and New York universities says removing that exclusion could create "the potential for considerable false-positive diagnosis and unnecessary treatment for grief-stricken persons."

Mr. Robbins shares that worry. "You could have all the things that look like major depression -- your sleep is disordered and you're having a hard time going to bed because things are racing through your mind and you lack hope and you're sad most of the day -- but it really could be a normal human response to the loss of a spouse or child."

The humanistic psychology group's letter has received support from Allen Frances, a retired Duke University psychiatrist who chaired the last revision of the manual, the DSM-IV.

"My biggest concern," Dr. Frances wrote in a recent column, "is that [the DSM-5] will dramatically increase the rates of mental disorder and cheapen the currency of psychiatric diagnosis by ... reducing thresholds for existing disorders and by introducing new high-prevalence disorders at the boundary with normality. Unless corrected, DSM-5 may create millions of newly mislabeled 'patients.' "

One other uproar that has hit the DSM-5 involves a proposed new diagnosis for autism.

The current manual contains four separate autism categories, and "because the criteria were rather vague and unclear on how they were written," Dr. Regier said, "children have been diagnosed differently at different centers around the world and it became increasingly clear that they were really all on a spectrum."

The new autism spectrum category would cover children and adults with mild to severe symptoms of the disorder, and would define the hallmarks as communication and social interaction difficulties on the one hand and repetitive behaviors or interests on the other.

Some autism experts and parents of autistic children worry that the new category will exclude many children who are now labeled as autistic, possibly denying them educational and other services they now get.

Based on field trials that are testing the new diagnostic standards, Dr. Regier said he doesn't anticipate a big drop-off in people getting the autism label.

In the midst of these debates, one California psychiatrist said it's important to remember that the manual is just a book.

Steve Balt, a San Francisco area psychiatrist who writes a blog called Thought Broadcast, said the fears of psychiatrists overprescribing drugs are real, "but what seems to be missing in this debate is that somebody in the middle has to be doing the overprescribing -- it's not the book that's doing it."

While the DSM may just be a book, others say it's a book with a huge real-world impact because it is often the main guidepost used by health insurance companies for whether to pay for certain therapies or drugs.

For that reason, said Dr. Regier and psychiatric researcher Helena Kraemer, the DSM-5 Task Force is doing widespread field tests to make sure the diagnoses are reliable and clear enough for everyday psychiatrists to use.

Last year, 11 major adult and children's hospitals around the nation tested the DSM-5 categories on real patients, with the goal of seeing whether two different doctors would independently give a patient the same diagnosis no more than two weeks apart.

The results of those field tests will determine whether a category such as attenuated psychosis syndrome becomes a full-fledged diagnosis or is put in the "back of the book" for further study when the DSM-5 manual is published next year, the two researchers said.

The field trials wrapped up last October, but Dr. Regier said the task force is still analyzing the results.

Some of the debate swirling around the DSM-5 reflects older tensions between psychiatry, which is the only mental health profession authorized to prescribe medication, and psychology and social work, which provide most talk therapists.

Mr. Robbins said there is good reason to suspect that too many people are getting psychiatric drugs.

"The enormous profitability of psychotropic medications for the pharmaceutical industry naturally motivates the industry to expand the market for these drugs as far as it possibly can," he wrote last year in the Journal of Psychological Issues in Organizational Culture.

"Indeed, the pharmaceutical industry spends far more on sales than it does on research of new medication. As a result, the large financial influence of pharmaceutical marketing threatens to undermine the credibility of psychiatric practice."

In the long run, Ms. Kraemer noted, any improvements in how patients are diagnosed and treated will depend on well-designed scientific studies.

And those studies depend on being able to enroll patients who have the proper diagnosis in the first place.

"The reason the DSM is so important," she said, "is because you need to have the right people in clinical studies of any type to get valid results."

Mark Roth: or 412-263-1130. First Published January 30, 2012 5:00 AM


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