Your Child's Tantrums and Irritability
Are Now Being Classed As Psychiatric Disorders
Childhood temper tantrums, teenage irritability and binge eating
are now to be classed as psychiatric disorders in the US, according
to proposed changes to the Diagnostic and Statistical Manual, the
bible of the psychiatric profession.
"Illness is always a social construct," notes Dr. Nortin
Hadler, professor of medicine and microbiology/immunology at the
University of North Carolina at Chapel Hill, and author of the book
"Worried Sick: A Prescription for Health in an Overtreated
"People have to agree -- both people, in general, and those
in the medical community -- that a life experience should be labeled
an illness," Hadler says. "For example, the Victorians
medicalized orgasm, and we medicalize the lack of it."
The proposals from the Diagnostic and Statistical Manual (DSM)
are the product of a 10-year effort to update the handbook, which
influences the vast network of American healthcare providers,
insurance companies, courts, prisons and universities. At stake
are billions of dollars in insurance payments, pharmaceutical
sales and medical fees. The proposed revisions, published online
today , will be subject to public comment until late April.
"It not only determines how mental disorders are diagnosed,
it can impact how people see themselves and how we see each other,"
Alan Schatzberg, president of the American Psychiatric Association,
which publishes the guide, told reporters. "It influences
how research is conducted as well as what is researched. It affects
legal matters, industry and government programmes."
The DSM is in its fourth edition. It has been criticised for
formalising character traits and emotions into mental conditions
and for encouraging their medical treatment, often with drugs
that have powerful side effects.
Christopher Lane, a professor at Northwestern University and
author of 2007 DSM critique Shyness: How Normal Behavior Became
a Sickness, said: "The organisation is clearly opening another
Pandora's box here, as well as paving the way for the medication
of even-greater numbers of children and teenagers cycling through
emotional stages as part of normal development."
Dr. Igor Galynker, director of The Family Center for Bipolar Disorder
at Beth Israel Medical Center in New York, says that some psychiatric
conditions, in particular, tend to be a target of widespread controversy.
"In psychiatry, part of a disorder is clinically defined
and part is societally defined," he says, adding that conditions,
such as Attention Deficit Disorder, or ADD, are particularly contentious.
"An ADD diagnosis is very controversial, especially after
a recent paper suggested some children with ADD 'grow out' of
it at age 25," he says. "That would mean that ADD is
a phase in development, rather than a disease. ... It is all fluid."
In an email, Christopher Lane said that categorising binge eating
as a psychiatric disorder risks classifying millions of Americans
as mentally ill at a time when the country is trying to rein in
health care costs.
Among the proposals is a new condition, "temper dysregulation
with dysphoria", characterised by "severe, recurrent
outbursts of temper" several times a week, that are "grossly
out of proportion to the situation or provocation and that interfere
significantly with functioning". To be considered, the "symptoms"
must have been "diagnosed" before age 10.
The proposed revisions would also recognise binge eating as a
disorder. The condition is "characterised by recurring episodes
of the consumption of unusually large amounts of food, accompanied
by a sense of loss of control and strong feelings of embarrassment
and guilt". These episodes would need to occur at least once
a week over the last three months, and the writers were keen to
distinguish it from mere overeating.
"While overeating is a challenge for many Americans, recurrent
binge eating is much less common and far more severe and is associated
with significant physical and psychological problems," wrote
Dr B Timothy Walsh.
The panels proposed a new category of condition called "risk
syndromes", in which a patient is at risk for a mental disorder
that is not yet present.
For example, a moody teenager who displays "excessive suspicion,
delusions and disorganised speech or behaviour" may be labelled
as having psychosis risk syndrome. The panel estimated that a
quarter to a third of people who suffer from those "symptoms"
go on to develop a psychotic disorder, and the writers acknowledged
the new category could lead to inaccurate diagnosis of some who
are not at risk.
"Given the severity of psychotic disorders, and evidence
that early treatment may mitigate its long-term consequences,
we believed that it was important to begin to recognise these
conditions as early as possible," wrote Dr William Carpenter
of the American Psychiatric Association's psychotic disorders
The panels who proposed the revisions also took into account
how race, ethnicity and gender affect the incidence of psychiatric
disorders, and studied how those categories affect the expression
of symptoms. For example, researchers noted differing ways of
experiencing and describing symptoms of panic among some Asian
and Hispanic patients.
The panel also recommended discarding the term "mental retardation"
in diagnoses, replacing it with "intellectual disability".
February 16, 2010