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  1. Redefining Crazy: ResearchersRevise the DSMBy JOHN CLOUDWednesday, Mar. 11, 2009If you wanted to make a list of important books you should read, what would youchoose? Anna Karenina, maybe? The Bible? How about the Diagnostic andStatistical Manual of Mental Disorders?It may not be at the top of your list, but the DSM, as its usually called, is one of themost important books in the world. It attempts to categorize, describe and give acode number to literally every problem that can occur in your mind, fromschizophrenia to borderline personality disorder to something called mathematicsdisorder, which is essentially being so bad at math that it amounts to a mentalproblem.The DSM is important not only because it is wildly ambitious but also becausemental-health professionals around the world have adopted its classificationsystem. In the U.S., it is virtually impossible to get reimbursed by an insurancecompany for treatment unless a mental-health professional identifies your conditionby a DSM code number. (The number for mathematics disorder, if you werewondering, is 315.1. The code for Tourettes syndrome is 307.23; the code forsexual sadism is 302.84. As I said, the DSM tries to cover everything.) (See the top10 medical breakthroughs of 2008.)The American Psychiatric Association (APA), which owns the DSM, is in theprocess of rewriting the book, which was first published in 1952. The DSM-V, asthe fifth edition will be called, is set to be published in 2012. But the process ofresearching it began way back in 1999 — five years after the publication of the lastmajor revision, the DSM-IV — meaning the new books production will take 13years overall. (Read about how we get labeled by the DSM.)Why so long? Last week, a research organization called the AmericanPsychopathological Association (which goes by the acronym APPA, to distinguishit from the APA) brought many of the key players in the development of the DSM-Vto a conference in New York City to discuss some of the reasons the writing of thebook is so complicated.One obvious reason is that so many people have a stake in what the world definesas crazy and what it calls normal. Famously, homosexuality was listed as a DSMcondition until a 1974 vote among APA members removed it. Other groups ofmental-health professionals and patients want certain disorders to be added (andcovered by insurance): sexual compulsivity, for instance, is not in the DSM, eventhough "sexual aversion disorder" (302.79) — the persistent and distressingavoidance of genital contact not explained by another disorder like depression — isincluded. (Read an interview with an author who has bipolar disorder.)Debates about what should and shouldnt be in the DSM are fascinating and oftenbitter, and as I have pointed out before, the book makes at least one fundamental
  2. error in the way it conceives of mental problems: it ignores causes almost entirely.If you feel sad and tired for a couple of months, have trouble sleeping and makingdecisions, and gain weight, you can be given a DSM diagnosis of depression(296.31 or 296.32, mild or moderate, recurrent) and prescribed drugs for it — evenif the reason for your funk is that you just lost your job. Such physiologicalresponses as insomnia are evolutionarily natural (and sometimes helpful, in ajump-starting sort of way) when you suffer a trauma like losing your job. Butaccording to the DSM, only perfect is considered normal. Another basic problemwith the DSM: it tries to reduce the vastly complex experiences of your mind to asingle number.At last weeks conference, there were tantalizing hints that the DSM-V might fixsome of these problems. Dr. Steven Hyman, provost of Harvard, a formerpsychiatry professor at its medical school and a former director of the NationalInstitute of Mental Health, agitated at the meeting for a new DSM framework thatwould stop trying to divide mental problems into discrete all-or-nothing categories.That method is appropriate for some medical problems — you either haveleukemia or you dont — but depression, for instance, doesnt work like that. (Read"Why Do the Mentally Ill Die Younger?")Rather, Hyman argued that many mental illnesses are problems that lie along acontinuum from normal and functioning to disordered and tragic. To the annoyanceof some old-fashioned DSM defenders, he made the case that the DSM shouldregard mental illness as "continuous with normal": less like leukemia and more likehypertension. You dont get diagnosed with hypertension until you meet a cutoffpoint for high blood pressure that takes into account other extenuating factors: yourage, for instance, or the conditions under which the blood-pressure reading istaken. Depression should be the same: if you are sad because you just gotdivorced, the DSM shouldnt necessarily consider you to have an illness.Such a diagnostic model wouldnt be simple, though, which is one reason the DSMis taking 13 years to rewrite. And in the meantime, the book still has to be useful toeveryday clinicians seeing patients who need a code number for insurancecompanies. "Its like wondering how you repair the airport while the planes are stillflying," Hyman said at the conference.Hyman noted that medical problems, whether in the mind or in the body or both,are usually caused by some combination of genes, environment, behavior andchance. Despite the comforting modern notion that severe psychological illnessesare simply due to an unfortunate genetic inheritance, it is the exceedingly raremental condition that is caused only by genes. (Rett syndrome is one example.)Rather, if you take something like generalized anxiety disorder (300.02), there maybe a variety of causes that set it off: genes that cause excessive activity in the fear-producing part of the brain called the amygdala, a stressful job that stimulates thatactivity, engaging in dumb behavior like having an affair that exacerbates youranxiety, then randomly getting into an anxiety-heightening situation like a caraccident. The DSM has to try to account for all of that complexity — causes,effects, unintended consequences — and still be definitive.Hyman said in an interview that one way the DSM currently handles this complexityis to have what he described as a "wastebasket" diagnosis — called "not otherwisespecified" (NOS) — that captures just about anything that doesnt easily fit the
  3. categorical model. One major problem with the NOS diagnosis: pretty muchanyone can qualify for a diagnosis that, by definition, is not specified. A 2005American Journal of Psychiatry paper found that nearly half of a group of 859people who sought psychological help in Rhode Island could be considered tohave a DSM personality disorder if diagnosticians were allowed to include the NOSoption. Another problem: how do you adequately treat patients whose illness isunspecified?A continuum model like the one Hyman proposes could help solve this problem byrecognizing that people arent always one thing or another. Theyre sometimes justa little depressed or a little anxious. To avoid medicalizing normal stress, the DSM-V would set a cutoff point within the spectrum. Of course, determining the rightcutoff point for the DSMs 350 illnesses would take an enormous research effort,one that has begun for some disorders like depression but probably hasnt evenbeen thought about for rare problems like sexual sadism.Other attendees at the APPA conference indicated that the new DSM will almostcertainly adopt a continuum model for mental illnesses. But dont be surprised if thebook doesnt come out as scheduled in 2012. If the three-day conference came toany solid conclusion, it was that toting up all the ways our minds can fail is a lotharder than, say, explaining why your appendix might burstRead more:http://www.time.com/time/health/article/0,8599,1884092,00.html#ixzz28r2yn2RS
  4. DSM-5 Could Categorize40% of College Students asAlcoholicsMost college binge drinkers and drug users don’t developlifelong problems. But new mental-health guidelines willlabel too many of them addicts and alcoholics.By MAIA SZALAVITZ | @maiasz | May 14, 2012 |Are you or have you ever been a college binge drinker? Welcome toalcoholism, a diagnosis your college self could qualify for under thechanges proposed to the next edition of psychiatry‟s diagnostic manual,the DSM-5.As the New York Times noted on Saturday in an article that rapidlybecame one of the most emailed, the DSM-5, short for the Diagnosticand Statistical Manual of Mental Disorders 5, will have just onediagnosis for addiction problems, though they will be characterized aseither mild, moderate or severe. Currently, alcohol and other drugproblems come in two flavors. The first, “substance abuse” is a short-term, self-limiting problem: it encompasses most heavy drinking incollege. The second “substance dependence,” is what everyone else callsaddiction or alcoholism and is typically chronic and marked byrelapses.Fortunately, the new diagnosis will get rid of the confusing term“dependence” (physically needing a drug to function isn‟t actuallyaddiction) and the stigmatizing term “abuse.” Unfortunately, however,it will also tremendously elevate the number of people consideredalcoholics. One Australian study suggested that using DSM-5definitions will increase the number of people diagnosed withalcoholism by a stunning 60%.The Times’ Ian Urbina writes:
  5. “The chances of getting a diagnosis are going to be much greater, andthis will artificially inflate the statistics considerably,” said Thomas F.Babor, a psychiatric epidemiologist at the University of Connecticutwho is an editor of the international journal Addiction. Many of thosewho get addiction diagnoses under the new guidelines would have onlya mild problem, he said, and scarce resources for drug treatment inschools, prisons and health care settings would be misdirected.“These sorts of diagnoses could be a real embarrassment,” Dr. Baboradded.Proponents of the new system argue that it will allow substanceproblems that might develop into serious addictions to be nipped in thebud:“We can treat them earlier,” said Dr. Charles P. O’Brien, a professor ofpsychiatry at the University of Pennsylvania and the head of the groupof researchers devising the manual’s new addiction standards. “Andwe can stop them from getting to the point where they’re going to needreally expensive stuff like liver transplants.”Yet because it‟s impossible to determine which college bingers willmoderate after graduation and who will go on to have lifetimeproblems, the distinction between abuse and dependence is difficult topinpoint. The reality is that most college binge drinkers and drug usersdon‟t develop lifelong problems. But most addiction treatmentprograms encourage them to see themselves as having a chronic,relapsing disease that requires a lifetime of attendance at 12-stepmeetings to keep in check. Currently, about 31% of college studentsmeet criteria for “alcohol abuse,” while only 6% have the alcoholism-equivalent diagnosis of dependence.Earlier editions of the DSM explicitly said there are alcohol and otherdrug problems that legitimately exist but do not reach the level ofaddiction; Alcoholics Anonymous itself differentiates between“problem drinkers” who can learn to moderate and alcoholics whocan‟t. DSM-5 obliterates the distinction. If the change is finalized,anyone whose drinking or drug use creates any problems willessentially be an addict or alcoholic with a “mild” case of the diseaseand presumably, therefore, not someone who can learn control over hishabits.While researchers have been encouraging the widespread adoption of
  6. “brief interventions” and other techniques that don‟t require abstinenceor a label — with great success — this change could swing the field inthe opposite direction.And that poses a huge problem, particularly for adolescents and youngadults with mild problems who may be pushed to adopt an addictidentity and to see themselves as having no way to control theirdrinking or drug use if they ever “relapse.” Rather than empoweringthose who do have control to use it, these programs essentially tell kidsthat if they ever have just one drink or puff on a joint, they‟re lost.While that strategy may help some people with addiction avoid relapse,research shows that it makes relapses worse if they do occur. And giventhat the overwhelming majority of teens who are treated will notremain abstinent for life, this strategy is counterproductive for mostwho will be exposed to it.In my years of covering addiction, I‟ve heard the story dozens of times:someone with a mild problem enters treatment, is convinced they havea more severe case and meets others who help him or her get worse.One teenage girl told me about meeting someone who turned her on tococaine while in treatment for marijuana; another young man told mehow treatment was the source of his perception that “who I was, was analcoholic and drug addict.”Clearly, treatment for young people already labels too many of them asaddicts and alcoholics; the last thing we need is the DSM legitimizingthis harmful practice. It should rename substance abuse “substancemisuse,” and label addiction, “addiction.” From any perspective, it‟sabsurd to potentially label the 40% of college students who get drunk atleast once a month as having “mild” alcoholismRead more: http://healthland.time.com/2012/05/14/dsm-5-could-mean-40-of-college-students-are-alcoholics/#ixzz28r3l2IHj
  7. Good Grief! Psychiatry‟sStruggle to Define MentalIllness Goes AwryA proposed new definition of depression would includenormal bereavement. Why thats a bad idea.By MAIA SZALAVITZ | @maiasz | February 17, 2012 |20The editors of the forthcoming fifth edition of the Diagnostic andStatistical Manual — psychiatry‟s diagnostic handbook — are having ahard time. They‟ve been attacked by autism advocacy groups forproposing to eliminate the Asperger‟s diagnosis. They‟ve been slammedfor adding a diagnosis, or “prediagnosis,” for people determined to be“at high risk” of developing schizophrenia. And, now, they‟re beingpummeled for introducing a provision to diagnose grief as depression.It has not gone unnoticed that the illnesses for which proposeddefinitions have been expanded are mainly those that are treatable bydrugs — antipsychotics or antidepressants, for which manufacturersseek increased marketing opportunities — while the contractions tendto be in conditions for which no specific medication is available.Indeed, the suggestion to label normal grief as depression would allow,for example, a bereaved widow to “treat” the sadness over the loss ofher husband with Prozac — a condition that previously would havebeen remedied with time and family support. Meanwhile, otherdiagnoses that the DSM-5„s editors have rejected — includingdevelopmental trauma disorder for children whose mental problemscan be best explained by early negative experiences, such as beingshuttled between multiple foster homes — often share the quality of notbeing easily amenable to pharmacological solutions.This week, the editors of the prestigious journal The Lancet weighed instrongly on the mourning-as-mental-illness debate. The authors write:Medicalising grief, so that treatment is legitimised routinely withantidepressants, for example, is not only dangerously simplistic, but
  8. also flawed. The evidence base for treating recently bereaved peoplewith standard antidepressant regimens is absent. In many people, griefmay be a necessary response to bereavement that should not besuppressed or eliminated.The journal cites psychiatrist Kay Redfield Jamison, who suffers frombipolar disorder. She noted in her memoir about mourning herhusband that she sees “a sanity to grief,” unlike her experience of theshifts in mood unlinked to external events that occur in bipolardisorder.In a separate column in The Lancet, Dr. Arthur Kleinman, a professorof psychiatry at Harvard Medical School who lost his wife toAlzheimer‟s, notes:Professor David J. Kupfer, who chairs the DSM-5 Task Force makingthe revisions, is reported to have told The New YorkTimes that makinggrief into a disease would allow psychiatrists to treat people who weresuffering so that they would get the treatment they need for beingdepressed. And that’s the rub really. Is grief something that we can orshould no longer tolerate? Is this existential source of suffering like anydental or back pain unwanted and unneeded?To me — as someone who has suffered both depression independent oflife experience and grief over the loss of my father — these are the rightquestions to ask. I self-medicated my depression with heroin andcocaine and became addicted, so I have also learned how to distinguishbetween the pathological desire to escape ordinary experience and thenecessary treatment of excessive emotional pain.The critical distinction between useful and needless suffering comesdown to its meaning and effects. Losing a beloved parent matters; itwould feel wrong not to hurt over it. But being deeply wounded over aminor perceived social slight, or being unable to work because you‟reconstantly tormented by self-hatred makes far less sense. Thedifference between illness and grief is proportionality and context —and in the context of a loved one‟s death, grief should be rightly givenprecedence.What strikes me as most absurd about defining mourning asdepression is the argument that it‟s necessary to allow medication to be
  9. prescribed to the bereaved. There‟s no evidence that people who wantantidepressants — including those who are in mourning — areroutinely denied for lack of cause. Indeed, doctors are currently free toprescribe drugs “off label” as they wish in just these types of cases.There aren‟t masses of prescription-seeking mourners in the streetsdemanding change.Of course, it makes sense for bereaved people who also suffer chronicdepression to be able to get help adjusting their medications so thatgrief doesn‟t push them back into unremitting illness. But again, there‟snothing stopping doctors from doing this now and such people arealready diagnosed with depression.The proposed changes to the DSM-5 risk making psychiatry into acaricature by medicalizing everyday experience. They add to the stigmaand public distrust of valid mental illnesses like depression by eliding itwith normal mourning. Depression is not ordinary sadness, andneither is grief. The latter is a proportionate response to emotionalcatastrophe, which ultimately ennobles us; the former is an emotionalcatastrophe removed from its source, which simply corrodes.By failing to make this fundamental distinction, psychiatrists riskmaking depressed people look like hedonists seeking to avoid normallife struggles, and mourners seem to be people who are improperlyovervaluing what is in fact the most valuable experience of all, deephuman connection. If we want to be mentally healthy, we need to beclear about these differences. Consequently, if psychiatrists really wantto help their patients, they need to stand up to the DSM-5 editors andpharmaceutical companies to ensure that mental illnesses and normalextreme experiences are defined appropriately.Read more: http://healthland.time.com/2012/02/17/good-grief-psychiatrys-struggle-to-define-mental-illness-goes-awry/#ixzz28rhBncTn

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