Symptoms or Circuits? The Future of Diagnosis
Source Credit: PSYPOST
We live in the most exciting and unsettling period in the history of psychiatry since Freud started talking about sex in public.
On the one hand, the American Psychiatric Association has introduced the fifth iteration of the psychiatric diagnostic manual, DSM-V, representing the current best effort of the brightest clinical minds in psychiatry to categorize the enormously complex pattern of human emotional, cognitive, and behavioral problems. On the other hand, in new and profound ways, neuroscience and genetics research in psychiatry are yielding insights that challenge the traditional diagnostic schema that have long been at the core of the field.
“Our current diagnostic system, DSM-V represents a very reasonable attempt to classify patients by their symptoms. Symptoms are an extremely important part of all medical diagnoses, but imagine how limited we would be if we categorized all forms of pneumonia as ‘coughing disease,” commented Dr. John Krystal, Editor of Biological Psychiatry.
A paper by Sabin Khadka and colleagues that appears in the September 15th issue of Biological Psychiatry advances the discussion of one of these roiling psychiatric diagnostic dilemmas.
One of the core hypotheses is that schizophrenia and bipolar disorder are distinct scientific entities. Emil Kraepelin, credited by many as the father of modern scientific psychiatry, was the first to draw a distinction between dementia praecox (schizophrenia) and manic depression (bipolar disorder) in the late 19th century based on the behavioral profiles of these syndromes. Yet, patients within each diagnosis can have a wide variation of symptoms, some symptoms appear to be in common across these diagnoses, and antipsychotic medications used to treat schizophrenia are very commonly prescribed to patients with bipolar disorder.
But at the level of brain circuit function, do schizophrenia and bipolar differ primarily by degree or are there clear categorical differences? To answer this question, researchers from a large collaborative project called BSNIP looked at a large sample of patients diagnosed with schizophrenia or bipolar disorder, their healthy relatives, and healthy people without a family history of psychiatric disorder.
They used a specialized analysis technique to evaluate the data from their multi-site study, which revealed abnormalities within seven different brain networks. Generally speaking, they found that schizophrenia and bipolar disorder showed similar disturbances in cortical circuit function. When differences emerged between these two disorders, it was usually because schizophrenia appeared to be a more severe disease. In other words, individuals with schizophrenia had abnormalities that were larger or affected more brain regions. Their healthy relatives showed subtle alterations that fell between the healthy comparison group and the patient groups.
The authors highlight the possibility that there is a continuous spectrum of circuit dysfunction, spanning from individuals without any familial association with schizophrenia or bipolar to patients carrying these diagnoses. “These findings might serve as useful biological markers of psychotic illnesses in general,” said Khadka.
Krystal agreed, adding, “It is evident that neither our genomes nor our brains have read DSM-V in that there are links across disorders that we had not previously imagined. These links suggest that new ways of organizing patients will emerge once we understand both the genetics and neural circuitry of psychiatric disorders sufficiently.”
Related articles
Social Anxiety: Another Side To The Struggle
Read Original Research Paper HERE (Free PDF internal link)
From ScienceDaily (Mar. 19, 2010) — When you think of people suffering from social anxiety, you probably characterize them as shy, inhibitive and submissive. However, new research from psychologists Todd Kashdan and Patrick McKnight at George Mason University suggests that there is a subset of socially anxious people who act out in aggressive, risky ways — and that their behavior patterns are often misunderstood.
In the new study published in Current Directions in Psychological Science, Kashdan and McKnight found evidence that a subset of adults diagnosed with Social Anxiety Disorder were prone to behaviors such as violence, substance abuse, unprotected sex and other risk-prone actions. These actions caused positive experiences in the short-term, yet detracted from their quality of life in the longer-term.
“We often miss
the underlying problems of people around us. Parents and teachers might think their kid is a bully, acts out and is a behavior problem because they have a conduct disorder or antisocial tendencies,” says Kashdan. “However, sometimes when we dive into the motive for their actions, we will find that they show extreme social anxiety and extreme fears of being judged. If social anxiety was the reason for their behavior, this would suggest an entirely different intervention.”
Kashdan and McKnight suggest that looking at the underlying cause of extreme behavior can help us understand the way people interact within society.
“In the adult world, the same can be said for managers, co-workers, romantic partners and friends. It is easy to misunderstand why people are behaving the way we do and far too often we assume that the aggressive, impulsive behaviors are the problem. What we are finding is that for a large minority of people, social anxiety underlies the problem,” says Kashdan.
The researchers suggest that further studies of this subset group can help psychologists better understand and treat the behaviors. “Recent laboratory experiments suggest that people can be trained to enhance their self-control capacities and thus better inhibit impulsive urges and regulate emotions and attention,” says McKnight. “Essentially, training people to be more self-disciplined — whether in physical workout routines or finances or eating habits — improves willpower when their self-control is tested.”
Credit: George Mason University
Read Original Research Paper HERE (Free PDF internal link)
Borderline Personality Disorder: What’s with the Name & Just What Is It?
I have continued to receive a number of requests by email and on Twitter about Borderline Personality Disorder, its name, its presentation, its treatment and its psycho-genesis. Below is a brief post which I think covers most of these questions in outline form. I am open to suggestions as to which, if any areas readers would like to discuss in more detail. A small collection of books on BPD which I recommend to patients, carers, significant others and counsellors can be found here, most with reader reviews. I would be happy to hear of others.
What’s with the name?
The term “borderline” was first used by early psychiatrists to describe people who were thought to be on the “border” between diagnoses. At the time, the system for diagnosing mental illness was far less sophisticated than it is today, and “borderline” referred to individuals who did not fit neatly into the two broad categories of mental disorder: psychosis or neurosis.
Today, far more is known about BPD, and it is no longer thought of as being related to psychotic disorders (and the term “neurosis” is no longer used in our diagnostic system). Instead, BPD is recognized as a disorder characterized by intense emotional experiences and instability in relationships and behavior.
Many experts are now calling for BPD to be renamed, because the term “borderline” is outdated and because, unfortunately, the name has been used in a stigmatizing way in the past. Suggestions for the new name have included: “Emotion Dysregulation Disorder,” Unstable Personality Disorder,” and “Complex Posttraumatic Stress Disorder.”
Borderline personality disorder (BPD) is a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior. This instability often disrupts family and work life, long-term planning, and the individual’s sense of self-identity. Originally thought to be at the “borderline” of psychosis, people with BPD suffer from a disorder of emotion regulation. While less well known than schizophrenia or bipolar disorder (manic-depressive illness), BPD is more common, affecting 2 percent of adults, mostly young women.1 There is a high rate of self-injury without suicide intent, as well as a significant rate of suicide attempts and completed suicide in severe cases.2,3 Patients often need extensive mental health services, and account for 20 percent of psychiatric hospitalizations.4 Yet, with help, many improve over time and are eventually able to lead productive lives.
Symptoms
While a person with depression or bipolar disorder typically endures the same mood for weeks, a person with BPD may experience intense bouts of anger, depression, and anxiety that may last only hours, or at most a day.5 These may be associated with episodes of impulsive aggression, self-injury, and drug or alcohol abuse. Distortions in cognition and sense of self can lead to frequent changes in long-term goals, career plans, jobs, friendships, gender identity, and values. Sometimes people with BPD view themselves as fundamentally bad, or unworthy. They may feel unfairly misunderstood or mistreated, bored, empty, and have little idea who they are. Such symptoms are most acute when people with BPD feel isolated and lacking in social support, and may result in frantic efforts to avoid being alone.
People with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes towards family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). Thus, they may form an immediate attachment and idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all. Even with family members, individuals with BPD are highly sensitive to rejection, reacting with anger and distress to such mild separations as a vacation, a business trip, or a sudden change in plans. These fears of abandonment seem to be related to difficulties feeling emotionally connected to important persons when they are physically absent, leaving the individual with BPD feeling lost and perhaps worthless. Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments.
People with BPD exhibit other impulsive behaviors, such as excessive spending, binge eating and risky sex. BPD often occurs together with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other personality disorders.
Treatment
Treatments for BPD have improved in recent years. Group and individual psychotherapy are at least partially effective for many patients. Within the past 15 years, a new psychosocial treatment termed dialectical behavior therapy (DBT) was developed specifically to treat BPD, and this technique has looked promising in treatment studies.6 Pharmacological treatments are often prescribed based on specific target symptoms shown by the individual patient. Antidepressant drugs and mood stabilizers may be helpful for depressed and/or labile mood. Antipsychotic drugs may also be used when there are distortions in thinking.7
Recent Research Findings
Although the cause of BPD is unknown, both environmental and genetic factors are thought to play a role in predisposing patients to BPD symptoms and traits. Studies show that many, but not all individuals with BPD report a history of abuse, neglect, or separation as young children.8 Forty to 71 percent of BPD patients report having been sexually abused, usually by a non-caregiver.9 Researchers believe that BPD results from a combination of individual vulnerability to environmental stress, neglect or abuse as young children, and a series of events that trigger the onset of the disorder as young adults. Adults with BPD are also considerably more likely to be the victim of violence, including rape and other crimes. This may result from both harmful environments as well as impulsivity and poor judgement in choosing partners and lifestyles.
NIMH-funded neuroscience research is revealing brain mechanisms underlying the impulsivity, mood instability, aggression, anger, and negative emotion seen in BPD. Studies suggest that people predisposed to impulsive aggression have impaired regulation of the neural circuits that modulate emotion.10 The amygdala, a small almond-shaped structure deep inside the brain, is an important component of the circuit that regulates negative emotion. In response to signals from other brain centers indicating a perceived threat, it marshals fear and arousal. This might be more pronounced under the influence of drugs like alcohol, or stress. Areas in the front of the brain (pre-frontal area) act to dampen the activity of this circuit. Recent brain imaging studies show that individual differences in the ability to activate regions of the prefrontal cerebral cortex thought to be involved in inhibitory activity predict the ability to suppress negative emotion.11
Serotonin, norepinephrine and acetylcholine are among the chemical messengers in these circuits that play a role in the regulation of emotions, including sadness, anger, anxiety, and irritability. Drugs that enhance brain serotonin function may improve emotional symptoms in BPD. Likewise, mood-stabilizing drugs that are known to enhance the activity of GABA, the brain’s major inhibitory neurotransmitter, may help people who experience BPD-like mood swings. Such brain-based vulnerabilities can be managed with help from behavioral interventions and medications, much like people manage susceptibility to diabetes or high blood pressure.7
Future Progress
Studies that translate basic findings about the neural basis of temperament, mood regulation, and cognition into clinically relevant insights which bear directly on BPD represent a growing area of NIMH-supported research. Research is also underway to test the efficacy of combining medications with behavioral treatments like DBT, and gauging the effect of childhood abuse and other stress in BPD on brain hormones. Data from the first prospective, longitudinal study of BPD, which began in the early 1990s, is expected to reveal how treatment affects the course of the illness. It will also pinpoint specific environmental factors and personality traits that predict a more favorable outcome. The Institute is also collaborating with a private foundation to help attract new researchers to develop a better understanding and better treatment for BPD.
References
1Swartz M, Blazer D, George L, Winfield I. Estimating the prevalence of borderline personality disorder in the community. Journal of Personality Disorders, 1990; 4(3): 257-72.
2Soloff PH, Lis JA, Kelly T, Cornelius J, Ulrich R. Self-mutilation and suicidal behavior in borderline personality disorder. Journal of Personality Disorders, 1994; 8(4): 257-67.
3Gardner DL, Cowdry RW. Suicidal and parasuicidal behavior in borderline personality disorder. Psychiatric Clinics of North America, 1985; 8(2): 389-403.
4Zanarini MC, Frankenburg FR. Treatment histories of borderline inpatients. Comprehensive Psychiatry, in press.
5Zanarini MC, Frankenburg FR, DeLuca CJ, Hennen J, Khera GS, Gunderson JG. The pain of being borderline: dysphoric states specific to borderline personality disorder. Harvard Review of Psychiatry, 1998; 6(4): 201-7.
6Koerner K, Linehan MM. Research on dialectical behavior therapy for patients with borderline personality disorder. Psychiatric Clinics of North America, 2000; 23(1): 151-67.
7Siever LJ, Koenigsberg HW. The frustrating no-mans-land of borderline personality disorder. Cerebrum, The Dana Forum on Brain Science, 2000; 2(4).
8Zanarini MC, Frankenburg. Pathways to the development of borderline personality disorder. Journal of Personality Disorders, 1997; 11(1): 93-104.
9Zanarini MC. Childhood experiences associated with the development of borderline personality disorder. Psychiatric Clinics of North America, 2000; 23(1): 89-101.
10Davidson RJ, Jackson DC, Kalin NH. Emotion, plasticity, context and regulation: perspectives from affective neuroscience. Psychological Bulletin, 2000; 126(6): 873-89.
11Davidson RJ, Putnam KM, Larson CL. Dysfunction in the neural circuitry of emotion regulation – a possible prelude to violence. Science, 2000; 289(5479): 591-4.
Bernstein, PhD, David P., Iscan, MD, Cuneyt, Maser, PhD, Jack, Board of Directors, Association for Research in Personality Disorder, & Board of Directors, International Society for the Study of Personality Disorders. “Opinions of personality disorder experts regarding the DSM-IV Personality Disorders classification system.” Journal of Personality Disorders, 21: 536-551, October 2007.
Sources: about.com and nimh.gov.org
Asperger’s, PDD-NOS may no longer receive separate diagnoses in DSM-V
Recently, the American Psychiatric Association released some preliminary draft changes to the Diagnostic and 
Statistical Manual of Mental Disorders (DSM-V) that may affect those diagnosed on the autism spectrum. There are several significant changes proposed that are now posted for public view, including: Asperger’s Syndrome and Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) would both be subsumed into the Autistic Disorder category, meaning that they would no longer be considered a separate diagnosis from autism, and the inclusion of potential co-morbidities with ADHD and other medical conditions.
The Autism Society is currently investigating the implications this change could have for the service and support systems currently in place for those with autism spectrum disorders. We will also be holding a town hall meeting at the Autism Society’s National Conference on Autism Spectrum Disorders in Dallas July 7–10, 2010 (learn more about the conference or register at www.autism-society.org/conference). You can also give your feedback on the changes at the Web site www.DSM5.org – look for the diagnoses on the autism spectrum under “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.”
These changes are not yet official – they are proposed for the update to the manual, which is expected to be published in May 2013. Whatever changes do go into effect surrounding autism spectrum disorders, the Autism Society will continue to work as we have always done to improve the lives of people across the entire spectrum of autism.
Borderline Personality Disorder: What’s with the Name & Just What Is It?
I have had a number of requests by email and on Twitter about Borderline Personality Disorder, its name, its presentation, its treatment and its psycho-genesis. Below is a brief post which I think covers most of these questions in outline form. I am open to suggestions as to which, if any areas readers would like to discuss in more detail. A small collection of books on BPD which I recommend to patients, carers, significant others and counsellors can be found here, most with reader reviews. I would be happy to hear of others, and I will also add a few more over the next few days.
What’s with the name?
The term “borderline” was first used by early psychiatrists to describe people who were thought to be on the “border” between diagnoses. At the time, the system for diagnosing mental illness was far less sophisticated than it is today, and “borderline” referred to individuals who did not fit neatly into the two broad categories of mental disorder: psychosis or neurosis.
Today, far more is known about BPD, and it is no longer thought of as being related to psychotic disorders (and the term “neurosis” is no longer used in our diagnostic system). Instead, BPD is recognized as a disorder characterized by intense emotional experiences and instability in relationships and behavior.
Many experts are now calling for BPD to be renamed, because the term “borderline” is outdated and because, unfortunately, the name has been used in a stigmatizing way in the past. Suggestions for the new name have included: “Emotion Dysregulation Disorder,” Unstable Personality Disorder,” and “Complex Posttraumatic Stress Disorder.”
Borderline personality disorder (BPD) is a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior. This instability often disrupts family and work life, long-term planning, and the individual’s sense of self-identity. Originally thought to be at the “borderline” of psychosis, people with BPD suffer from a disorder of emotion regulation. While less well known than schizophrenia or bipolar disorder (manic-depressive illness), BPD is more common, affecting 2 percent of adults, mostly young women.1 There is a high rate of self-injury without suicide intent, as well as a significant rate of suicide attempts and completed suicide in severe cases.2,3 Patients often need extensive mental health services, and account for 20 percent of psychiatric hospitalizations.4 Yet, with help, many improve over time and are eventually able to lead productive lives.
Symptoms
While a person with depression or bipolar disorder typically endures the same mood for weeks, a person with BPD may experience intense bouts of anger, depression, and anxiety that may last only hours, or at most a day.5 These may be associated with episodes of impulsive aggression, self-injury, and drug or alcohol abuse. Distortions in cognition and sense of self can lead to frequent changes in long-term goals, career plans, jobs, friendships, gender identity, and values. Sometimes people with BPD view themselves as fundamentally bad, or unworthy. They may feel unfairly misunderstood or mistreated, bored, empty, and have little idea who they are. Such symptoms are most acute when people with BPD feel isolated and lacking in social support, and may result in frantic efforts to avoid being alone.
People with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes towards family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). Thus, they may form an immediate attachment and idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all. Even with family members, individuals with BPD are highly sensitive to rejection, reacting with anger and distress to such mild separations as a vacation, a business trip, or a sudden change in plans. These fears of abandonment seem to be related to difficulties feeling emotionally connected to important persons when they are physically absent, leaving the individual with BPD feeling lost and perhaps worthless. Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments.
People with BPD exhibit other impulsive behaviors, such as excessive spending, binge eating and risky sex. BPD often occurs together with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other personality disorders.
Treatment
Treatments for BPD have improved in recent years. Group and individual psychotherapy are at least partially effective for many patients. Within the past 15 years, a new psychosocial treatment termed dialectical behavior therapy (DBT) was developed specifically to treat BPD, and this technique has looked promising in treatment studies.6 Pharmacological treatments are often prescribed based on specific target symptoms shown by the individual patient. Antidepressant drugs and mood stabilizers may be helpful for depressed and/or labile mood. Antipsychotic drugs may also be used when there are distortions in thinking.7
Recent Research Findings
Although the cause of BPD is unknown, both environmental and genetic factors are thought to play a role in predisposing patients to BPD symptoms and traits. Studies show that many, but not all individuals with BPD report a history of abuse, neglect, or separation as young children.8 Forty to 71 percent of BPD patients report having been sexually abused, usually by a non-caregiver.9 Researchers believe that BPD results from a combination of individual vulnerability to environmental stress, neglect or abuse as young children, and a series of events that trigger the onset of the disorder as young adults. Adults with BPD are also considerably more likely to be the victim of violence, including rape and other crimes. This may result from both harmful environments as well as impulsivity and poor judgement in choosing partners and lifestyles.
NIMH-funded neuroscience research is revealing brain mechanisms underlying the impulsivity, mood instability, aggression, anger, and negative emotion seen in BPD. Studies suggest that people predisposed to impulsive aggression have impaired regulation of the neural circuits that modulate emotion.10 The amygdala, a small almond-shaped structure deep inside the brain, is an important component of the circuit that regulates negative emotion. In response to signals from other brain centers indicating a perceived threat, it marshals fear and arousal. This might be more pronounced under the influence of drugs like alcohol, or stress. Areas in the front of the brain (pre-frontal area) act to dampen the activity of this circuit. Recent brain imaging studies show that individual differences in the ability to activate regions of the prefrontal cerebral cortex thought to be involved in inhibitory activity predict the ability to suppress negative emotion.11
Serotonin, norepinephrine and acetylcholine are among the chemical messengers in these circuits that play a role in the regulation of emotions, including sadness, anger, anxiety, and irritability. Drugs that enhance brain serotonin function may improve emotional symptoms in BPD. Likewise, mood-stabilizing drugs that are known to enhance the activity of GABA, the brain’s major inhibitory neurotransmitter, may help people who experience BPD-like mood swings. Such brain-based vulnerabilities can be managed with help from behavioral interventions and medications, much like people manage susceptibility to diabetes or high blood pressure.7
Future Progress
Studies that translate basic findings about the neural basis of temperament, mood regulation, and cognition into clinically relevant insights which bear directly on BPD represent a growing area of NIMH-supported research. Research is also underway to test the efficacy of combining medications with behavioral treatments like DBT, and gauging the effect of childhood abuse and other stress in BPD on brain hormones. Data from the first prospective, longitudinal study of BPD, which began in the early 1990s, is expected to reveal how treatment affects the course of the illness. It will also pinpoint specific environmental factors and personality traits that predict a more favorable outcome. The Institute is also collaborating with a private foundation to help attract new researchers to develop a better understanding and better treatment for BPD.
References
1Swartz M, Blazer D, George L, Winfield I. Estimating the prevalence of borderline personality disorder in the community. Journal of Personality Disorders, 1990; 4(3): 257-72.
2Soloff PH, Lis JA, Kelly T, Cornelius J, Ulrich R. Self-mutilation and suicidal behavior in borderline personality disorder. Journal of Personality Disorders, 1994; 8(4): 257-67.
3Gardner DL, Cowdry RW. Suicidal and parasuicidal behavior in borderline personality disorder. Psychiatric Clinics of North America, 1985; 8(2): 389-403.
4Zanarini MC, Frankenburg FR. Treatment histories of borderline inpatients. Comprehensive Psychiatry, in press.
5Zanarini MC, Frankenburg FR, DeLuca CJ, Hennen J, Khera GS, Gunderson JG. The pain of being borderline: dysphoric states specific to borderline personality disorder. Harvard Review of Psychiatry, 1998; 6(4): 201-7.
6Koerner K, Linehan MM. Research on dialectical behavior therapy for patients with borderline personality disorder. Psychiatric Clinics of North America, 2000; 23(1): 151-67.
7Siever LJ, Koenigsberg HW. The frustrating no-mans-land of borderline personality disorder. Cerebrum, The Dana Forum on Brain Science, 2000; 2(4).
8Zanarini MC, Frankenburg. Pathways to the development of borderline personality disorder. Journal of Personality Disorders, 1997; 11(1): 93-104.
9Zanarini MC. Childhood experiences associated with the development of borderline personality disorder. Psychiatric Clinics of North America, 2000; 23(1): 89-101.
10Davidson RJ, Jackson DC, Kalin NH. Emotion, plasticity, context and regulation: perspectives from affective neuroscience. Psychological Bulletin, 2000; 126(6): 873-89.
11Davidson RJ, Putnam KM, Larson CL. Dysfunction in the neural circuitry of emotion regulation – a possible prelude to violence. Science, 2000; 289(5479): 591-4.
Bernstein, PhD, David P., Iscan, MD, Cuneyt, Maser, PhD, Jack, Board of Directors, Association for Research in Personality Disorder, & Board of Directors, International Society for the Study of Personality Disorders. “Opinions of personality disorder experts regarding the DSM-IV Personality Disorders classification system.” Journal of Personality Disorders, 21: 536-551, October 2007.
Sources: about.com and nimh.gov.org
Bitterness, Compulsive Shopping, Internet Addiction & The Tyranny of Diagnosis
For those who have asked me about the usefulness or otherwise of diagnosis and the process of developing diagnostic criteria, here is a thought provoking article from slate.com’s Christopher Lane posted last week.
There’s an awful lot of money to be made from compulsive shopping, judging by the career of Madeleine Wickham. Her Shopaholic series, written under the pen name Sophie Kinsella, is required reading for chick-lit enthusiasts, and the romantic comedy Confessions of a Shopaholic, the first of several planned big-screen adaptations, grossed more than $100 million worldwide. While the film, starring Isla Fisher, isn’t terribly funny, it does make the valid point that to enjoy shopping for elegant clothes isn’t a pathology. It’s a style.
The American Psychiatric Association risks losing sight of that distinction by grimly—and rather inexpertly—debating whether avid shopping should be considered a sign of mental illness. The fifth edition of the association’s Diagnostic and Statistical Manual of Mental Disorders is expected in 2012. The APA isn’t just deciding the fate of shopaholics; it’s also debating whether overuse of the Internet, “excessive” sexual activity, apathy, and even prolonged bitterness should be viewed, quite seriously, as brain “disorders.” If you spend hours online, have sex more frequently than aging psychiatrists, and moan incessantly that the federal government can’t account for all its TARP funds, take heed: You may soon be classed among the 48 million Americans the APA already considers mentally ill.
Emily Yoffe explored the connection between Narcissistic Personality Disorder and economic collapse. David Greenberg discussed the history of presidential character assessment after John McCain released his entire mental-health profile. Daniel Engber wondered whether sex addiction is still a laughable affliction, and Larissa MacFarquhar defended the last DSM against its overdiagnosis-fearing critics.
Quite how the association will decide when normal kvetching becomes a sickness—or reasonable amounts of sex become excessive—is still anyone’s guess. Behind the APA’s doors in Arlington, Va., the fine points of the debate are creating quite a few headaches. And they’re also causing a rather public dust-up.
To linger anxiously, even bitterly, over job loss is all too human. To sigh with despair over precipitous declines in one’s retirement account is also perfectly understandable. But if the APA includes post-traumatic embitterment disorder in the next edition of its diagnostic bible, it will be because a small group of mental-health professionals believes the public shouldn’t dwell on such matters for too long.
That’s a sobering thought—enough, perhaps, to make you doubt the wisdom of those updating the new manual. The association has no clear definition of the cutoff between normal and pathological responses to life’s letdowns. To those of us following the debates as closely as the association will allow, it’s apparent that the DSM revisions have become a train wreck. The problem is, everyone involved has signed a contract promising not to share publicly what’s going on.
Back in 1952, when the APA’s diagnostic manual first appeared, it was a thin, spiral-bound edition that offered sketches of such ’50s-sounding traits as passive-aggressive personality disorder, emotionally unstable personality disorder, and inadequate personality disorder. It was seen more as a guide to psychiatry than as a chapter-and-verse authority on everything pertaining to mental health. Somehow it acquired those pretensions in 1980, with publication of the third edition, which included more than 100 new mental disorders, quite a few of them still being contested.
Inadequate personality wasn’t quite dropped from DSM-III; it was allowed to merge with “atypical, mixed, or other personality disorder,” which is, if anything, even more nebulous. Among the more hair-raising mental illnesses also added to the manual were avoidant personality disorder, oppositional defiant disorder, and social phobia. The latter’s symptoms to this day include fear of eating alone in public and concern that “one will act in a way … that will be humiliating and embarrassing.” The DSM also included such gems as caffeine intoxication disorder, mathematics disorder, sibling relational problem, and frotteurism, the “intentional rubbing up against or touching of another, usually unsuspecting, person for the purpose of sexual arousal.”
The DSM now contains three times as many disorders as it did in 1952 and is more than seven times longer than that first edition. The jury is still out on whether the dozens of new additions hold up to scientific scrutiny. Robert Spitzer, editor of two previous editions, including the one that formally approved post-traumatic stress disorder, recently conceded that his colleagues must now “save PTSD from itself.”
To its members and to the public, the APA boasts that the manual is rigorous and evidence-based, drawing meticulously on data and field trials. But the very fact that the APA has produced a task force to decide whether bitterness, apathy, extreme shopping, and overuse of the Internet belong in the manual indicates, as Allen Frances, who chaired the DSM-IV task force, told Psychiatric News last month, that DSM-V is “headed in a very wrong direction.” “I don’t think they realize the problems they are about to create,” he declared, “nor are they flexible enough to change course.”
Serious questions have also surfaced about the competence, procedure, and secrecy of the DSM-V task force. And the two most vocal skeptics are Frances and Spitzer, former editors of the manual. In one open letter, they chide the APA’s leaders for creating a “rigid fortress mentality,” insisting that “continuing problems … have forced us to intervene in so public a way.”
High on their list of concerns is the absence of transparency. Last July, Spitzer warned readers of Psychiatric News that the amount of secrecy cloaking the revisions was unprecedented and alarming. He quoted the contract that participants are required to sign, which reads, in part:
I will not, during the term of this appointment or after, divulge, furnish, or make accessible to anyone or use in any way … any Confidential Information. I understand that “Confidential Information” includes all Work Product, unpublished manuscripts and drafts and other pre-publication materials, group discussions, internal correspondence, information about the development process and any other written or unwritten information, in any form, that emanates from or relates to my work with the APA task force or work group.
The APA alleges that the paragraph was not meant to block input from interested colleagues or output to the media (for which we are still waiting, by the way!). The president of the APA and the vice chair of the DSM-V task force bluntly dismissed other complaints about secrecy, insisting, against all contrary evidence, that its procedure is “a model of transparency and inclusion.” The agreement was allegedly crafted to protect intellectual property. (The DSM is already copyrighted.) But the agreement also remains binding even after DSM-V is published; to avoid breaking it, participants must keep their drafts, memos, and working papers to themselves. Apparently we’re never to know exactly how or why bitterness, anger, and Internet addiction become mental disorders. Indeed, the contract appears to have been designed to make that omission a foregone conclusion—otherwise, why did the APA enforce it so rigidly at the start? When Spitzer requested the minutes of earlier discussions, he was told that if the APA made them available to him, it would need to share them with others.
After Frances made his objections public last month, he and Spitzer followed up by sending the APA an open letter: “Unless you quickly improve the internal APA DSM-V review process, there will inevitably be increasing criticism from the outside. Such public controversy will raise questions regarding the legitimacy of the APA’s continued role in producing subsequent DSMs—a result we would all like to avoid.”
Spitzer and Frances also strongly disagree with a proposal to include “subthreshold” and “premorbid” diagnoses in the new manual. Both terms give cover to the so-called “kindling” theory of mental illness in children and infants—some psychiatrists believe that it’s possible to stamp out ailments before they burgeon into full-blown disorders. In practice, as the St. Petersburg Times reported in March, psychiatrists in Florida alone gave antipsychotic drugs off-label (without formal FDA approval) in 2007 to 23 infants who were less than 1 year old at the time. They extended the practice to 39 toddlers aged 1; 103 aged 2; 315 aged 3; 886 aged 4; and 1,801 aged 5. One shudders to think what is going on in other states.
The kindling theory of infant mental disorders reminds us—as Darrel Regier (then the APA’s deputy medical director) told the FDA’s Psychopharmacologic Drugs Advisory Committee in October 2005—that the APA already considers 48 million Americans mentally ill. “Subthreshold” and “premorbid” diagnoses, warn Spitzer and Frances, “could add tens of millions of newly diagnosed ‘patients’ “—their quotation marks—to that roster, “the majority of whom would likely be false positives subjected to the needless side effects and expense of treatment.” Conceivably, we might by 2012 reach a point where the APA is defining more than half the country as mentally ill.
“In its effort to increase diagnostic sensitivity,” Spitzer and Frances conclude, the DSM-V task force “has been insensitive to the great risks of false positives, of medicalizing normality, and of trivializing the whole concept of psychiatric diagnosis.” These are remarkable accusations from two men who, between them, oversaw the formal approval of more than 150 mental disorders in two-dozen years.
In three years’ time, will bitterness be seen as one of these disorders? Count me among the afflicted, if you must; some days that does seem possible, even likely. Given its track record and the grave doubts of two former editors of the DSM, should the APA really be given sole rights to decide something so consequential?
Do We Need A Simpler Definition For Major Depressive Disorder?
I’ve just come across this press release. Thought provoking..will have to chew it over.
Researchers from Rhode Island Hospital’s department of psychiatry propose that the definition for major depressive disorder (MDD) should be shortened to include only the mood and cognitive symptoms that have been part of the definition in the Diagnostic and Statistical Manual of Mental Disorders (DSM) for the past 35 years. Their recommendation would exclude those symptoms that are currently part of the definition that may be associated with medical illness rather than depression. The proposal is based on a study that appears in the July 23 online first edition of the journal Psychological Medicine.
The current definition of major depressive disorder in the fourth edition of the DSM (DSM-IV) includes nine 
symptoms — a definition that has remained essentially unchanged since the 1970s. With preparations for the fifth edition of the DSM underway, the researchers propose that there are two practical problems with the symptom criteria: the length of the definition and the difficulty in applying some of the criteria to patients with co-morbid medical illnesses. The researchers’ proposal recommends a shortened list of symptom criteria that includes only low mood, loss of interest or pleasure, guilt/worthlessness, impaired concentration/indecision and suicidal thoughts. It would exclude the somatic criteria of fatigue, appetite disturbance and sleep disturbance (increased sleep or insomnia) as these may be associated with medical illnesses other than depression. Their proposal is called the “simpler definition of MDD.”
Lead author Mark Zimmerman, MD, director of outpatient psychiatry at Rhode Island Hospital, says, “While the principles guiding criteria revision have not been clearly explained, we believe that existing diagnostic criteria should be revised when a conceptual problem is identified, or a more valid or simpler method of defining a disorder is developed. The reason for even considering a change to the symptom criteria for major depressive disorder after all these years is two-fold.”
Zimmerman, who is also an associate professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University, continues, “First, studies have indicated that there are significant gaps in the knowledge or application of the MDD criteria among practitioners. Second, somatic criteria that are currently part of the DSM-IV definition such as fatigue or sleep or appetite disturbances are also symptoms of other medical illnesses and may not be indicative of a major depressive episode.”
Under Zimmerman’s direction, researchers from Rhode Island Hospital and The Warren Alpert Medical School of Brown University previously developed the simpler definition of MDD for a project known as the Rhode Island Methods to Improve Diagnostic Assessment and Services (RI MIDAS) project, an integration of research quality diagnostic methods into a community-based outpatient practice affiliated with an academic medical center.
Zimmerman says, “In our previous report from the RI MIDAS project, we developed a briefer list of the symptom criteria of MDD that was composed entirely of the DSM-IV mood and cognitive symptoms. That simplified definition did not include the somatic symptoms.” He continues, “Our initial research found high levels of agreement in diagnosing MDD between the simplified and DSM-IV definitions of MDD. Our goal in this study was to replicate these findings in a large sample of psychiatric outpatients, and to extend the findings to other patient populations, including those presenting for treatment of pathological gambling and candidates for bariatric surgery.”
Zimmerman says, “After eliminating the four somatic criteria from the DSM-IV definition of MDD, leaving the five mood and cognitive features, a high level of concordance was found between this simpler definition of MDD with the original classification in all three patient samples studied.” He adds, “This new definition offers two advantages over the DSM-IV definition – it is briefer and therefore more likely to be recalled and correctly applied in clinical practice, and it is free of somatic symptoms, thereby making it easier to apply with medically ill patients.”
Using the Structured Clinical Interview for DSM-IV (SCID), the researchers conducted a study of more than 2,500 patients. The patient population consisted of 1,100 psychiatric outpatients, 210 pathological gamblers who presented for treatment and 1,200 candidates for bariatric surgery. Across all patients, the level of agreement between the simplified definition and the DSM-IV definition was more than 95 percent.
The researchers note that there are implications to changing the criteria for MDD. Because their findings indicate that the simpler definition is highly concordant with the current version, there would be no meaningful impact on prevalence rates. Reducing the number of criteria, however, would reduce the time needed to fully assess criteria in patients and diagnostic interviews could be shortened.
Zimmerman and the researchers conclude, “In deciding how to proceed in the next version of the DSM, the conceptual and practical advantages of a briefer set of criteria that is easy to apply to all patients, particularly medically ill patients, needs to be weighted against the disadvantages of deviation from tradition.”
Along with Zimmerman, other researchers involved in the study include Janine Galione, PhD; Iwona Chelminski, PhD; Joseph McGlinchey, PhD; Diane Young, PhD; Kristy Dalrymple, PhD; Camile Ruggero, PhD; and Caren Francione Witt, PhD; all of Rhode Island Hospital and Brown University.
Source: Nancy Jean Lifespan
//
What do you think? Leave a comment and we’ll see if we can get some discussion happening!
About Peter
Peter Brown BHMS (Hons) MPsychClin MAPS
I’m a Clinical Psychologist and have a private practice and consultancy in Brisbane Australia. I have 24 years experience in child, adult and family clinical psychology. I have a wonderful wife and three kids.
I am co-founder of Christian Wholeness Counselling Services.
I like researching issues of the brain & mind, reading and seeking out new books and resources for myself and my clients. I thought that others might be interested in some of what I have found also, hence this blog…
Subscribe to My Blog Posts & Updates
-
Blog Surfer
Alphainventions
Recent Comments
Peter H Brown Clinical Psychologist 