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Psychiatrists debate changes to field manual

Book revisions could introduce new disorders

By Rob Stein
Washington Post / February 11, 2010

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WASHINGTON - Children who throw too many tantrums could be diagnosed with “temper dysregulation with dysphoria.’’ Teenagers who are particularly eccentric might be candidates for treatment for “psychosis risk syndrome.’’ Men who are too interested in sex face being labeled as suffering from “hypersexual disorder.’’

These are among dozens of proposals the American Psychiatric Association is unveiling for the first complete revision since 1994 of the Diagnostic and Statistical Manual of Mental Disorders, or DSM - the tome that has served as the bible for modern psychiatry for more than half a century.

The product of more than a decade of work by hundreds of experts, the proposed revisions are designed to bring the best scientific evidence to bear on psychiatric diagnoses and could have far-reaching implications, including determining who gets diagnosed as mentally ill, who should get powerful psychotropic drugs, and whether and how much insurance companies will pay for care.

“It not only determines how mental disorders are diagnosed, it can impact how people see themselves and how we see each other,’’ said Alan Schatzberg, the association’s president. “It influences how research is conducted as well as what is researched. . . . It affects legal matters, industry, and government programs.’’

The proposals will be debated in an intense process over the next two years, with potentially billions of dollars at stake for pharmaceutical companies, insurance companies, government health plans, doctors, researchers, and patient advocacy groups.

Perhaps more important, the outcome will help shape which emotions, behaviors, thoughts, and personality traits society considers part of the natural spectrum of the human persona and which are considered pathological, requiring treatment and possibly criminal punishment.

Even before being made public, the proposed changes have been the subject of bitter debate over whether the process was based on solid scientific evidence and was adequately shielded from influence by the pharmaceutical industry, and whether some critics were driven by financial interests in maintaining the old diagnostic criteria.

Supporters argue that the revisions would make diagnoses more accurate, creating more useful and precise definitions and sometimes reducing the number of psychiatric labels. For example, “autistic disorder’’ and “Asperger’s disorder’’ would be replaced with a new, single category called “autism spectrum disorders.’’ Critics fear the new diagnoses could unnecessarily stigmatize many people and lead to the unnecessary use of psychiatric medications.

“By massively pathologizing people under these categories, you tend to put them on an automatic path to medication, even if they are experiencing normal distress,’’ said Jerome Wakefield, a professor of social work and psychiatry at New York University.

After being posted on the Internet, the proposed changes will undergo a public comment period until April 20, studies to validate some of the changes, further review, and votes by the association’s board of trustees and assembly. A final version is expected to be released by May 2013.

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