Are you worried or ‘disordered?’
Psychiatry guidebook to set broader anxiety guidelines
Official psychiatry could soon make it easier for the chronically worried to be diagnosed as mentally “disordered” and in need of treatment.
Among the controversial changes anticipated in the newest edition of psychiatry’s manual of mental disorders, due to hit doctors’ offices in May, the thresholds for “generalized anxiety disorder” (GAD) are widely expected to be loosened, a move some observers say could make it more frequently diagnosed than depression.
The publishers of psychiatry’s guidebook of mental illness won’t discuss final diagnostic criteria until the manual is completed and published in the spring. But a leading U.S. psychiatrist who chaired the task force that wrote the current edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM, says the next manual will further obscure the “already fuzzy boundaries” between GAD and normal, everyday worries.
Ten years in the making, the latest edition of the DSM reflects the most upto-date science and understanding of dysfunction in the brain, leaders of the American Psychiatric Association said last week in announcing that its board of trustees has approved the final criteria for the fifth edition of the DSM.
But while the total number of diagnoses hasn’t changed — believed to be a first in the catalogue’s 60-year history — many of the early proposals that drew the most heated criticism have made it through.
They include “disruptive mood dysregulation disorder” — defined as children who exhibit “persistent irritability” and frequent “behaviour outbursts” — hoarding (people who have difficulty “discarding or parting with possessions”) binging and excoriation (skin picking) disorder.
Meanwhile, gone from the new manual will be “bereavement exclusion” for a diagnosis of major depressive disorder. Currently, people who have recently suffered a loss cannot be diagnosed with major depression unless their symptoms persist beyond two months. In the new manual, “grief exclusion” has been dropped. Instead of having to wait two months, the diagnosis could be made two weeks after the loss of a loved one.
Dr. Suzanne Renaud, president of the Canadian Psychiatric Association, says research and clinical observation are beginning to show that “maybe we need to consider at times that bereavement can become pathological if the person is not doing well.”
Renaud said choices had to be made about what psychiatric diagnoses should be added, dropped or revised.
Canadian medical historian Edward Shorter says what makes it into the DSM is more the result of “a lot of horse-trading around the table” than science — “‘I’ll give you your diagnosis if you give me mine,’ which is a fundamentally unscientific process,” says Shorter. “They didn’t come up with the speed of light this way.
“Psychiatry claims to be a medical specialty that is based on neuroscience, but the whole diagnostic system is very questionable,” said Shorter. “The current DSM series is, in my view, a scientific disaster and should be discarded.”
Others, too, are questioning the science behind the latest revisions.
“Disruptive mood dysregulation disorder? Temper tantrums, in a nutshell,” said Dr. Frank Farley, an Edmonton native and a past president of the American Psychological Association. “Hoarding disorder — where is the threshold? When does hoarding become ‘mentally sick?’ Where’s the tipping point?”
Proposed changes to the criteria for generalized anxiety disorder could lead to runaway diagnoses, with vast numbers of people experiencing normal anxiety misclassified as mentally sick and an expanded market for drug companies, said Dr. Allan Horwitz, a professor of sociology at Rutgers University in New Jersey. According to the proposed new definition, generalized anxiety disorder would capture people experiencing “unrealistic or excessive anxiety and worry” in two or more domains of life, such as family, health, finances or school or work problems.
“These are exactly the kinds of things we would expect people to be anxious about,” Horwitz said.