three false epidemics -- attention deficit disorder, autism and childhood bipolar disorder: It's not too late to save 'normal' in DSM-V

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It's not too late to save 'normal'

Psychiatry's latest DSM goes too far in creating new mental disorders.

By Frances

March 1, 2010

http://www.latimes.com/news/opinion/commentary/la-oe-frances1-2010mar01,0,203064\

1.story

As chairman of the task force that created the current Diagnostic and

Statistical Manual of Mental Disorders (DSM-IV), which came out in 1994,

I learned from painful experience how small changes in the definition of

mental disorders can create huge, unintended consequences.

Our panel tried hard to be conservative and careful but inadvertently

contributed to three false " epidemics " -- attention deficit disorder,

autism and childhood bipolar disorder. Clearly, our net was cast too

wide and captured many " patients " who might have been far better off

never entering the mental health system.

The first draft of the next edition of the DSM, posted for comment with

much fanfare last month, is filled with suggestions that would multiply

our mistakes and extend the reach of psychiatry dramatically deeper into

the ever-shrinking domain of the normal. This wholesale medical

imperialization of normality could potentially create tens of millions

of innocent bystanders who would be mislabeled as having a mental

disorder. The pharmaceutical industry would have a field day -- despite

the lack of solid evidence of any effective treatments for these newly

proposed diagnoses.

The manual, prepared by the American Psychiatric Assn., is psychiatry's

only official way of deciding who has a " mental disorder " and who is

" normal. " The quotes are necessary because this distinction is very hard

to make at the fuzzy boundary between the two. If requirements for

diagnosing a mental disorder are too stringent, some who need help will

be left out; but if they are too loose, normal people will receive

unnecessary, expensive and sometimes quite harmful treatment.

Where the DSM-versus-normality boundary is drawn also influences

insurance coverage, eligibility for disability and services, and legal

status -- to say nothing of stigma and the individual's sense of

personal control and responsibility.

What are some of the most egregious invasions of normality suggested for

DSM-V? " Binge eating disorder " is defined as one eating binge per week

for three months. (Full disclosure: I, along with more than 6% of the

population, would qualify.) " Minor neurocognitive disorder " would

capture many people with no more than the expected memory problems of

aging. Grieving after the loss of a loved one could frequently be

misread as " major depression. " " Mixed anxiety depression " is defined by

commonplace symptoms difficult to distinguish from the emotional pains

of everyday life.

The recklessly expansive suggestions go on and on. " Attention deficit

disorder " would become much more prevalent in adults, encouraging the

already rampant use of stimulants for performance enhancement. The

" psychosis risk syndrome " would use the presence of strange thinking to

predict who would later have a full-blown psychotic episode. But the

prediction would be wrong at least three or four times for every time it

is correct -- and many misidentified teenagers would receive medications

that can cause enormous weight gain, diabetes and shortened life expectancy.

A new category for temper problems could wind up capturing kids with

normal tantrums. " Autistic spectrum disorder " probably would expand to

encompass every eccentricity. Binge drinkers would be labeled addicts

and " behavioral addiction " would be recognized. (If we have

" pathological gambling, " can addiction to the Internet be far behind?)

The sexual disorders section is particularly adventurous.

" Hypersexuality disorder " would bring great comfort to philanderers

wishing to hide the motivation for their exploits behind a psychiatric

excuse. " Paraphilic coercive disorder " introduces the novel and

dangerous idea that rapists merit a diagnosis of mental disorder if they

get special sexual excitement from raping.

Defining the elusive line between mental disorder and normality is not

simply a scientific question that can be left in the hands of the

experts. The scientific literature is usually limited, never easy to

generalize to the real world and always subject to differing

interpretations.

Experts have an almost universal tendency to expand their own favorite

disorders: Not, as alleged, because of conflicts of interest -- for

example, to help drug companies, create new customers or increase

research funding -- but rather from a genuine desire to avoid missing

suitable patients who might benefit. Unfortunately, this therapeutic

zeal creates an enormous blind spot to the great risks that come with

overdiagnosis and unnecessary treatment.

This is a societal issue that transcends psychiatry. It is not too late

to save normality from DSM-V if the greater public interest is factored

into the necessary risk/benefit analyses.

Frances is professor emeritus and former chairman of the

department of psychiatry at Duke University.

Copyright © 2010, The Los Angeles Times

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