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If you thought grim things were forecast for 2012, just wait till 2013. An army of psychopaths will spring up overnight. Many of our friends and neighbours will suddenly develop alcohol problems. In fact, eminent psychiatrists fear that millions of us will slip over that ephemeral frontier that separates the normal from (to use the proper medical term) the Crazy.
That's because 2013 will see the fifth coming of the brain-doctor's bible, the Book that tells us who is normal and who has a "disorder" - the Diagnostic and Statistical Manual of Mental Disorders. Is that weird neighbour just a jerk or does he have a syndrome? DSM-5 will decide.
Maybe he's a psychopath. Because, after 33 years' absence, the honest psychopath makes his comeback in DSM-5. In DSMs III and IV, psychopaths were hidden under the euphemistic category of Antisocial Personality Disorder. But the latest draft of DSM-5 will brand these undesirables as Antisocial/Psychopathic Type, which has a fine condemnatory ring. In fact it sounds more like a judgement than a diagnosis. You can presumably cure a disorder, but can you cure a "type"?
If anyone thinks this is all just semantics, consider the impact in recent years of three disorders that were redefined by DSM-IV in 1994: attention deficit disorder, autism, and child bipolar disorder. The Chairman of the DSM-IV task force, psychiatrist Allen Frances, his panel "inadvertently contributed to three false 'epidemics'."
"I learned from painful experience how small changes in the definition of mental disorders can create huge, unintended consequences," wrote Dr Frances. "Clearly, our net was cast too wide and captured many 'patients' who might have been far better off never entering the mental health system."
DSM-5 offers the opportunity to undo some mistakes in DSM-IV. The autistic spectrum was a bit of a dog's breakfast, and the next iteration will try to bring it some order, doing away in the process with Asperger's Syndrome and the unpopular diagnosis Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS). It seems a little harsh on Dr Asperger, whose name is being de-immortalized, but fair enough.
But many more new diagnoses are trying to creep in, some pushed by eager researchers, others befriended by lawyers, all surely welcomed by big pharma. Each seeks to push the boundary between Normal and Crazy so that more people will fall into the second category. The draft includes a Hoarding Disorder. The proposed Mixed Anxiety Depression will capture millions who don't qualify for Major Depression but who constitute what we call 'the worrying type'. Irritable people who throw tantrums will have Disruptive Mood Dysregulation Disorder. There's Minor Neurocognitive Disorder for those with expected cognitive decline of ageing that's too mild to justify a diagnosis of Mild Neurocognitive Disorder .
There's also constant pressure to ease the criteria for existing conditions. A finds that the prevalence of alcohol use disorders is 62% higher under DSM-5 criteria than under DSM-IV. Adult ADD is also getting more broadly defined. It's the medicalization of normal, if bad, behaviour that scares Dr Frances and many other critics.
Book needs appendectomy
To be fair, most of the worst ideas come from outside the American Psychiatric Association committees responsible for the drafts. Some of the silliest have already been rejected. Divorce lawyers will not get their "parental alienation syndrome", which would have allowed them to counter child abuse allegations by alleging that Mommy had turned Johnny against Daddy.
Disorders that have made it this far in the process, however, are so far advanced that to ignore them would apparently be rude, so those that don't get a disease code are likely to end up in the Appendix on Axes for Further Study, which is beginning to sound like a smorgasbord of half-baked ideas, about as useful as a human appendix. One pseudo-condition that's already definitely heading there is Hypersexual Disorder, which has been derided as a philanderer's charter.
The behavioural "addictions" - shopping addiction, computer game addiction, internet addiction, will also be relegated to the appendix, except for compulsive gambling, which became officially crazy in 1994 with DSM-IV. It makes the leap from humble Impulse Disorder to become the first recognized Behavioural Addiction. Can the others be far behind?
One new condition that teeters between recognition and the obscurity of the appendix is Attenuated Psychosis Syndrome, a diagnosis intended to catch mostly young people who might be at risk of developing a real psychotic episode later in life, but who have never met any criteria for one. Those diagnosed, including the many false positives, would be treated with atypical antipsychotics, costly drugs with a heavy burden of side effects. The creators of DSM-5 declare themselves torn on this one, and welcome outside comment. In fact the whole process is in an open comment period until June 15. You can have your say .
Posted by David Elkins and others at 4:19 PM