THE PHILADELPHIA INQUIRER - Page 1 http://bit.ly/philadelphia-inquirer-occupyapa. 4 May 2012. By Stacey Burling INQUIRER STAFF WRITER
Conflict over changes in psychiatry bible. Critics say the proposed DSM-5 risks diagnosing normal pementally ill.
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.
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