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DSM-5, A Disaster for Childhood Diagnoses

The next edition of the diagnostic manual will make a bad situation worse.

American Psychiatric Association
Source: American Psychiatric Association

The Board of Trustees of the American Psychiatric Association tried yesterday to project confidence in the next edition of its problem-plagued manual, assuring Americans that radical changes to the DSM “passed” all necessary hurdles and represented a “major milestone” for American psychiatry.

But DSM-5 is now certain to include highly controversial changes, including approval of Attenuated Psychosis Syndrome and Disruptive Mood Dysregulation Disorder—proposals that sparked widespread concern and skepticism when first circulated. In addition to approving Hoarding and Binge Eating as new disorders, and dramatically lowering the threshold for Generalized Anxiety Disorder and several other conditions, the next edition of the manual will also delete the exclusion clause for bereavement, making it possible to pathologize grief and mourning if a person experiences them for more than two weeks.

The news that Attenuated Psychosis and Disruptive Mood Dysregulation will soon be bona fide mental disorders came after the decidedly mixed results of field trials costing the APA $3 million, in which nine out of 23 adult or child diagnoses, generated under real-world conditions, indicated “questionable” to “unacceptable” diagnostic reliability. That was after the APA had arbitrarily moved its goalposts, reclassifying as “very good” results that DSM-IV field trials apparently would have recorded as merely “okay.” Running out of time to complete its crucial second round of tests, the organization then decided to avoid conducting them altogether. As a result, no field trials designed to assess the certain rise in false positives, or misdiagnoses, took place for DSM-5.

Until it sparked major controversy earlier this year, “Disruptive Mood Dysregulation Disorder” was known as “Temper Dysregulation Disorder” (TDD). Its initial criterion, “severe recurrent temper outbursts in response to common stressors,” targeting children between the ages of 6 and 10, led to a debate on BBC Radio 4 that generated international coverage, making the pages of (among others) the Guardian, the Independent, the Daily Telegraph, the Daily Mail, the Financial Times, Irish Health, the French Tribune, the Times of India, Top News New Zealand, the Toronto Sun, Reuters, ABC News, and the New York Daily News. Just as “a lot of people suffer,” Peter Kinderman, Professor of Clinical Psychology at the University of Liverpool, warned in the debate, “it’s also important that people don't get help they don't need”—especially, he added, considering the “very powerful psychiatric drugs” that are often prescribed after diagnosis.

Cut to yesterday’s press announcement of the DSM-5 criteria. The approval of “Disruptive Mood Dysregulation Disorder,” the APA declared, to all intents and purposes resurrecting under a new name its earlier proposal for TDD, “is intended to address concerns about potential over-diagnosis and overtreatment of bipolar disorder in children.”

Even with its careful legalese acknowledging only the “potential over-diagnosis and overtreatment of bipolar disorder in children,” the statement is striking. Although the APA can’t officially accept an ounce of responsibility for the forty-fold increase in diagnoses of bipolar disorder in children, shortly after DSM-IV eliminated mania as a required symptom for Bipolar Disorder Type 2, the organization does fortunately seek to remedy the diagnostic crisis. The problem is, it’s taken entirely the wrong action, devising a new disorder to conceal problems in the framing and real-world application of previously defined ones.

Disruptive Mood Dysregulation Disorder, the APA’s press release notes of the work of just one research group, exists to “diagnose children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year.” The time stipulation is meant to reassure, establishing a high threshold for diagnosis that is certain to be breached, if not by the inevitable DSM 5.1 or 6.0, then by the same pediatricians who argued last fall that the threshold for ADHD should be lowered to include children as young as 4.

With psychiatrists and pediatricians frequently and notoriously confusing ADHD with Bipolar Disorder, while ADHD remains as widespread a diagnosis as ever, how successfully will the same groups be able to differentiate DMDD from these already existing disorders? Although the final wording of the criteria won't be released until DSM-5 appears in May, when the Associated Press tried to parse the differences in its press release, restating APA distinctions, it made clear just how blurry and unreliable they are: “Bipolar disorder involves sharp mood swings from feeling sad and depressed to unusually happy or energetic. Affected children are sometimes very irritable or have explosive tantrums. The new diagnosis [DMDD] would be given to children and adults who can’t control their emotions and have frequent temper outbursts in inappropriate situations.”

So children who “can’t control their emotions and have frequent temper outbursts” (i.e., DMDD) don’t at the same time experience “sharp mood swings” that render them sad, depressed, or “unusually happy or energetic” (i.e., BP)? Are “frequent temper outbursts” even possible without “sharp mood swings”?

With the APA more or less conceding that it’s created a new disorder to correct its own earlier diagnostic mistakes, the obvious solution was not to approve DMDD but to strengthen and tighten the criteria for Bipolar Disorder. Weak assurances, including by the APA’s President, Dilip Jeste, “that DSM is not a treatment manual and that diagnosis does not equate to a need for pharmacotherapy” ring hollow after seemingly minor changes to DSM-IV led to a skyrocketing increase in the use of atypical antipsychotics to treat children's behavioral problems.

What the APA has done, in short, is try to cover its tracks by creating yet another psychiatric condition—one that, like its predecessors, is an invitation for the drug companies to abuse its open-endedness. It’s a sleight of hand, as the APA seems partly to recognize and, given the stakes for public health and the overmedication of America’s children, an extremely troubling one.  Follow me on Twitter: @christophlane