The impending publication of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) has kindled fiery debate about whether Americans are being vastly over-diagnosed with mental illness or if Americans are psychologically sicker than they used to be.
The new "bible" of psychiatric diagnoses, which will be released later this month, includes new disorders relating to grief, childhood temper tantrums, binge eating, PMS, and painful sex (now called genito-pelvic pain/penetration disorder), among others. It has also changed how existing conditions—including oft-polarizing ADHD and autism—are diagnosed.
According to the new definitions the DSM-5 uses, some experts predict about 50 percent of U.S. citizens could be diagnosed as "mentally ill" at some point during their lifetime.
The DSM-5 changes were approved late last year, and since then, plenty of experts and organizations have weighed in on the pros and cons of the new guide.
According to the American Psychiatric Association—the group responsible for changes to the DSM-5—the new manual is “based on sound scientific data” compiled from “a comprehensive review of scientific advances.” The DSM-5 Task Force also posted frequent reports about the proposed changes on its website, including a detailed FAQ, and, starting in 2010, made hundreds of presentations at leading medical conferences around the world.
“At every step of development, we have worked to make the process as open and inclusive as possible,” said Dr. James H. Scully, the medical director and CEO of the American Psychiatric Association, in a Forbes interview. The Task Force has received some 13,000 comments from clinicians, researchers, and patients since 2010.
However, dozens of medical and patient advocacy groups have mounted attacks on the new guide. The National Institute of Mental Health (NIMH) weighed in with a statement from its director, Dr. Thomas Insel, saying, “The weakness [in the DSM-5] is its lack of validity." The NIMH says it will no longer be funding research projects based on DSM diagnoses and is working on developing its own diagnostic system.
Dr. Allen Frances—chair of the DSM-IV Task Force and author of Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life—fears that the backlash against the DSM-5 will cause the public and legislators to question the value of psychiatry. “Funding for mental healthcare has already been cut in many states, and many people who are mentally ill or even suicidal aren’t getting the help they desperately need,” he says.
In addition to the public backlash, Dr. Frances also predicts a false spike in mental disorders after the DSM-5 is released. “There will be massive diagnostic inflation that could lead to tens of millions of people receiving psychiatric drugs they don’t need,” he says.
Incorrectly prescribed psychiatric medication can have dangerous side effects—and may be especially dangerous for kids. For example, the FDA has mandated a “black box label warning” that certain antidepressants called SSRIs (selective serotonin reuptake inhibitors)—such as Prozac, Zoloft and Paxil, among others—may increase risk for suicidal behavior or thinking in teens and children.
Antipsychotic drugs—currently prescribed to more than 3 million Americans for such mental illnesses as bipolar disorder, severe depression, and schizophrenia—often cause weight gain, boosting risk for diabetes, high cholesterol, and heart disease. Other adverse effects can include dizziness, blurred vision, rapid heartbeat, tremors, and persistent muscles spasms, according to the NIMH.
The NIMH also reports that every year, about 5 percent of people taking typical antipsychotic drugs develop a disorder called tardive dyskinesia, which is an often chronic condition characterized by uncontrollable muscle movements, such as facial grimaces, repetitive chewing, tongue thrusting, or finger movements, that can range from mild to severe.
If you or your child receives a prescription for a psychiatric drug you think isn’t needed, ask lots of questions, advises Dr. Frances. “Any time a doctor wants to hand you a pill, you need to know why this medication is being advised, what its risks, benefits, and side effects are, and what other treatment options are available. If the answers don’t make sense to you, get a second opinion—or a third.”
The DSM-5 Task Force reports that it conducted “field trials” to evaluate the impact of certain diagnoses and estimates that, in general, the rates of these disorders using DSM-5 criteria “are slightly lower than DSM-IV prevalence.”
A coalition of 32 organizations—including divisions of the influential American Psychological Association (APA)—argue that the DSM-5 lowers the threshold for a diagnosis of mental illness and contributes to “excessive medicalization,” “stigmatization,” and “pathologization” of normal human responses and behavior.
For example, according to the DSM-5, grief over the death of a loved one could qualify as major depressive disorder if it lasts more than two weeks and the bereaved person experiences such symptoms as loss of appetite and interest in daily activities, trouble sleeping and focusing, and feelings of worthlessness or despair.
This change is one of the most controversial in the DSM-5, but some experts believe it will have a positive impact on patients. “While everyone experiences grief, for some people, a major loss can be a trigger for depression,” notes Dr. Daniel Amen, MD, a board-certified child and general psychiatrist with clinics in several cities. “Making the criteria more expansive could help those people be identified and treated sooner, thus reducing their suffering."
Additionally, “patients with hard-to-diagnose chronic pain risk being labeled with ‘somatic symptom disorder’ under new DSM-5 criteria if their doctor decides the problem is all in their heads,” says Dr. Frances, who is also former chair of psychiatry at Duke University School of Medicine in Durham, North Carolina.
The addition of these and other new disorders—including premenstrual dysphoric disorder (formerly included in an appendix to the DSM-IV), excoriation (skin picking), and hoarding disorder (a perceived need to save items and distress associated with discarding them)—means that insurance companies will now reimburse therapists or other healthcare providers for treating them.
If you’re unsure if your disorder is covered, contact your plan to discuss your mental health benefits, advises Dr. Amen. About 80 percent of patients with psychological symptoms receive their initial evaluation and diagnosis from a primary care provider—care that is typically covered under most plans, Dr. Amen and other experts report.
Some proposed disorders, including hypersexual disorder (sex addiction), were rejected by the Task Force, which also changed the diagnostic criteria for a number of existing disorders. If therapy for your disorder is not covered, you can still consult your primary care provider to discuss other treatment options or check for a support group in your area.
One of the most controversial new childhood disorders is called disruptive mood dysregulation disorder (DMDD), which requires kids to have at least three tantrums a week and frequent irritability for a year to be diagnosed. The Task Force came up with this diagnosis in a bid to address concerns about overdiagnosis of childhood bipolar disorder—a once rare condition that has skyrocketed by 40-fold during the past 15 years.
“The major problem with DMDD is that there is very little scientific data to support this diagnosis,” says child psychologist Tom Frazier, Ph.D., who heads the Cleveland Clinic Children’s Center for Autism. “The only data I’ve seen suggests that it will have a high overlap with existing conditions like ADHD and oppositional defiant disorder, so I honestly don’t know why it was included, except that a few people with influence pushed for it.”
Dr. Frances has another name for the temper-tantrum disorder. “These kids have a disease called childhood,” he says, admitting that the DSM-IV Task Force he headed in the 1990s inadvertently created an “epidemic of overdiagnosis” by adding two then-new mental disorders to the manual, autism and bipolar disorder II (an adult disorder sometimes applied to children).
“Both changes made sense to us, but now one in 50 kids is being diagnosed with autism—a 300 percent rise over the past decade—while rates of childhood bipolar disorder have skyrocketed,” says Dr. Frances, who now anticipates a surge in ADHD diagnosis in both kids and adults. The DSM-5 reduces the number of symptoms adults need to qualify for this already common label from six to five and raises the age limit by which symptoms must start. The DSM-IV required that "symptoms that caused impairment were present before age 7 years," while the DSM-5 expands the definition to "several inattentive or hyperactive-impulsive symptoms were present prior to age 12."
Because ADHD (also known as ADD) is often treated with stimulant drugs, such as Ritalin and Dexadrine, an increase in diagnosis means even more kids are likely to experience such medication side effects as loss of appetite, sleep problems and mood swings, says Dr. Amen, who is also author of Healing ADD. “It’s frightening that about 20 percent of teenage boys are already receiving an ADHD diagnosis.”
However, adds Dr. Amen, “when the right child receives these medications, dramatic changes can occur, such as D’s and F’s in school turning into A’s and B’s.”
Some parents of kids with autism worry about the impact of sweeping changes in its definition that could influence whether their child qualifies for government, educational, and insurance benefits.
The DSM-5 will now fold Asperger’s disorder, autism disorder, childhood disintegrative disorder, and pervasive developmental disorder into a single condition called autism spectrum disorder, which the American Psychiatric Association believes will lead to more accurate diagnosis, reports the Autism Society.
“Children, adults, anyone with autism, should not be reevaluated for the purposes of the DSM-5,” notes Alycia Halladay, Ph.D., Autism Speaks senior director, Environmental and Clinical Sciences. “The diagnosis of autism [under the DSM-IV] will stay autism; a diagnosis is stable. No one should lose any sort of services, support, or therapies that they currently have.”
However, she says, “We recognize that there may be some misunderstanding on the part of clinicians and service providers.” Another concern is that children with impairments, who would have been diagnosed as autistic under the DSM-IV, may now go undiagnosed.
Some experts, including Dr. Frazier of the Cleveland Clinic, consider such fears overblown. “The impact on children with autism will probably be very small, with about 2 percent, mainly high-functioning kids, being affected by the changed criteria,” he predicts.
Dr. Halladay reports that the research has been mixed: several small studies found that 20 to 50 percent of people with autism might go undiagnosed under the DSM-5. However, a 2012 multi-center study of about 4,400 children with pervasive developmental disorder found that 91 percent would qualify for an autism diagnosis under the new criteria.
Children who don’t meet the DSM-5 criteria for autism might also fall within the definition of the new social communication disorder (SCD), in which patients have communication impairments similar to autism, but do not exhibit repetitive movements. Because it is a diagnosable psychiatric disorder, Dr. Halladay notes that children with SCD would likely qualify for healthcare services and therapies through their insurance provider.
Dr. Halladay adds that in circumstances in which parents have a concern, and the doctor does not, she says, “The first thing to do would be to see another doctor.”
To gauge the effects of these changes, Autism Speaks—a leading autism research and advocacy organization—is launching an online survey at the end of this month where parents can report if their child is reevaluated and their diagnosis changes.
Don’t panic if you get a new diagnosis, says Harvard-affiliated psychotherapist Jean Fain, MSW, LICSW. “Just because your problem has a new name, such as binge-eating disorder or body dysmorphic disorder, doesn’t necessarily mean that your treatment will change. Talk to your therapist about how the change will influence your care.”
Also discuss the diagnostic criteria for the disorder. “It’s important to be an educated patient, so look up the condition online, discuss it with your doctor, and ask your family and friends if the symptoms match what they’ve observed,” suggests Dr. Frances.
“If the new label seems stigmatizing or doesn’t seem to fit your situation, ask your therapist if there’s another diagnosis that you’d be more comfortable with,” adds Fain.
And if you feel that you’ve been misdiagnosed, consult another mental health professional. To find one, ask your health plan for a list of participating mental health providers in your area, then ask your friends and colleagues if they know a therapist who can make recommendations based on that list.
“Other patients are great resources,” says Dr. Frances, who also emphasizes that it may take several visits to a therapist to get an accurate diagnosis.
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