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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 America."

"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 work group.

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

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