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DSM-5 Controversy Is Now Firmly Transatlantic

Why the APA's lower diagnostic thresholds are causing widespread concern.

Proposed draft revisions to the DSM, which the American Psychiatric Association recently made available on its website, are stirring major controversy on both sides of the Atlantic.

With the number of signatures petitioning the revisions reaching 11,544 and a raft of international mental health organizations urging the APA to drop its proposed inclusion of "disruptive mood dysregulation disorder," "complicated grief disorder," and other questionable illnesses, the press in the U.S. and United Kingdom is now actively debating the proposals, in the process raising serious doubts and concerns about the APA's rationale for pursuing them.

In just the past few weeks, the New York Times alone has run several major articles on proposed adjustments to the definition of depression ("Grief Could Join List of Disorders"), autism, and Asperger syndrome ("Asperger's History of Overdiagnosis"), in part owing to the manual's highly elastic parameters and significantly lowered thresholds. Two Sundays ago, the Times also published an eloquent, well-researched op-ed called "Ritalin Gone Wrong," which on the basis of rigorous long-term studies dared to ask of the "three million children" in the U.S. who "take drugs for problems in focusing": "Are these drugs really helping children? Should we really be expanding the number of prescriptions filled?"

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Yesterday in the UK, it was BBC Radio 4's turn on the "Today Programme" to debate the proposed inclusion of disruptive mood dysregulation disorder (hereafter DMDD) and mild neurocognitive disorder, in a segment called "Quirk or Mental Illness?" Arguing (as the New York Times op-ed did) that it was "important to stop vast numbers of children from being prescribed very powerful psychiatric drugs" they frequently don't need, Peter Kinderman, Professor of Clinical Psychology at the University of Liverpool, took the opportunity to urge the APA "to pause and rethink" its proposal to make either behavioral trait a bona-fide mental disorder.

Kinderman made clear that he had two "major worries" about the APA's proposals: "A lack of fit" between the scientific research and how "people's behavior" was being made to "hang together in diagnostic groups," and that "large numbers of the diagnostic thresholds have been lowered" to make many more individuals eligible for a diagnosis.

He noted that DMDD was "broadly translatable to 'having temper tantrums'" and that "mild neurocognitive disorder" was tantamount to targeting seniors for "being a bit forgetful." Such concern about the proposals is perfectly reasonable. After all, the first proposed criterion for DMDD (previously known as Temper Dysregulation Disorder) is "severe recurrent temper outbursts in response to common stressors." Mild neurocognitive disorder, incredibly, is currently a proposal without symptoms, but the APA is encouraging concerned experts and lay readers to check back soon as "the criteria will be forthcoming."

"It's very important we get the definition and description of emotional problems right," Kinderman stressed, in a debate that has since made the pages of the Guardian, the Independent, the Daily Telegraph, the Daily Mail, Financial Times, Irish Health, French Tribune, Times of India, TopNews New Zealand, Toronto Sun, Reuters, Healthcare Global, ABC News, the Chicago Tribune, and the New York Daily News. Just as "a lot of people suffer, ... it's also important that people don't get help they don't need," owing to the "very powerful psychiatric drugs" that are often prescribed after diagnosis.

David Kupfer, chair of the DSM-5 task force, tried to defend both proposals even as he dodged questions about the rising number of signatories to the DSM-5 petition and tried to assure the millions of Britons listening that the new edition will be "much more stringent" than the current one.

Unfortunately, the exact same promises have accompanied the release of every new DSM edition, only to dash the hopes of those who define stringent as the dictionary does, as strict, precise, exacting, and austere. In the late 1980s, for example, it was the turn of social anxiety disorder to be labeled an "epidemic"—shortly after the APA decided to lower the threshold for that trait to include such routine fears as public-speaking anxiety. Other key revisions at the time made sure that the anxiety needed only to be anticipated and could include such criteria as concern "that he or she may do something or act in a way that will be humiliating or embarrassing."

So much for the APA's stringency. What was driving the organization's support for DMDD, Kupfer insisted, was "an epidemic with respect to bipolar disorder in young individuals." What he couldn't of course add was that the APA's expanded criteria had, once again, helped to create just such an epidemic by ensuring that millions more children and adults met the newly-lowered threshold.

The APA's lower thresholds across the board help explain why we've seen "a twentyfold increase in the consumption of drugs for attention-deficit disorder," L. Alan Sroufe, professor emeritus of psychology at the University of Minnesota's Institute of Child Development, wrote in the Times op-ed "Ritalin Gone Wrong." Yet "putting children on drugs does nothing to change the conditions that derail their development in the first place." On the contrary, he noted, "policy makers are so convinced that children with attention deficits have an organic disease that they have all but called off the search for a comprehensive understanding of the condition."

"The illusion that children's behavior problems can be cured with drugs prevents us as a society from seeking the more complex solutions that will be necessary," Sroufe warned. "Drugs get everyone—politicians, scientists, teachers and parents—off the hook. Everyone except the children, that is."

If David Kupfer's response yesterday is anything to go by, the APA is sure to continue defending its proposals tooth and nail, no matter how poorly considered they are. Still, it's worth recalling Kupfer's earlier words to the Chicago Tribune, when the scandal then embroiling the APA was its initial push for total secrecy over DSM-5 deliberations: "'One of the raps against psychiatry is that you and I are the only two people in the U.S. without a psychiatric diagnosis,' said Kupfer, head of the psychiatry department at the University of Pittsburgh."

Tribune writer Ron Grossman went on to add from his 2008 interview with the DSM-5 chair: "Kupfer said he hopes to reduce the number of diagnostic categories in the forthcoming edition of the DSM ... He argues that scientific progress comes from formulating ideas, then seeing if others can shoot them down. If currently listed maladies fail that test, they'll be dropped, Kupfer said."

www.christopherlane.org

Christopher Lane, Ph.D., teaches literature and intellectual history at Northwestern University and is the author of Shyness: How Normal Behavior Became a Sickness. more...

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