Psychiatrists Wrestle With Defining Disorders (Again) [latimes.com]

Psychiatrists are in the thick of a years-long effort to produce the latest edition of the essential textbook for diagnosing mental illnesses, the DSM. They’re dogged by controversies over ‘new’ conditions.

By Shari Roan, Los Angeles Times – May 22, 2011

“Where are we going to put the narcissists?”

It was a question asked urgently by one of the hundreds of psychiatrists gathered here last week for their professional society’s annual meeting. With doctors in the thick of a years-long effort to rewrite the essential textbook for diagnosing mental illnesses, questions like these came up time and again in meeting rooms, over drinks sipped from coconut shells, and in other venues during the five-day conference.

Among the myriad proposals now on the table: reducing the number of specific personality disorders from 10 to five, a move that would eliminate the diagnosis of narcissistic disorder.

“Of course there are narcissists!” the psychiatrist insisted in the convention’s vast exhibit hall, where new research papers were displayed next to pharmaceutical-industry booths. “We see them all the time!”

Don’t let the cheery Hawaiian shirts fool you — the nation’s psychiatrists aren’t feeling all that ku’u aku (relaxed) as the deadline nears for the next edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5.The first revision in almost 20 years will roll off the presses in 2013. Since the 1994 edition, research has exposed pieces of the biological framework underlying disorders likeschizophreniaanorexia and depression. But molecular tests and brain scans based on those discoveries aren’t yet ready for diagnostic use, and that leaves the authors of the upcoming book with the same problem that vexed their predecessors: how to distinguish a mental illness from the rainbow of normal human behavior.

Much of the discussion at the American Psychiatric Assn. meeting centered on fears that, without solid scientific evidence, additions or deletions in their new bible of mental health could do more harm than good.

“The brain is so darn complicated,” said Dr. David Axelson, director of the Child and Adolescent Bipolar Services program at the Western Psychiatric Institute in Pittsburgh.

As with each edition, the controversies dogging DSM-5 center on the proposed “new” conditions. Among the questions:

• Is there a distinct mood disorder that occurs in some women prior to their periods?

• Is hoarding a brain-based illness?

• Can the sorrow accompanying bereavement swell into a certifiable mental disorder?

Even when concepts are not at issue, nomenclature sometimes is. Suggestions include replacing the word “anxiety” with “worry,” and scrapping the terms “addiction,” “dependence” and “substance abuse” in favor of “substance-use disorder.”

“We have to be very careful about our choice of language and precise criteria,” said Dr. David J. Kupfer, the DSM-5 task force chairman and director of research at Western Psychiatric Institute and Clinic. Slight word changes could translate into making a disorder much more prevalent — or much more rare, he said.

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