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New Psychiatric Disorders and Their Social Side Effects

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The American Psychiatric Association has just published the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition). Added to the psychiatric disorders previously named (minus a few), the manual lists 15 new disorders ranging from caffeine withdrawal syndrome to restless legs syndrome along, with hoarding disorder and premenstrual dysphoric disorder.

Controversies surround the new manual. For instance, mourning (or bereavement) may be considered a mental disorder, according to the new manual. Formerly, it was viewed as a normal reaction to a significant loss in one's life, unless it was very extended and resulted in obvious symptoms and maladaptive behavior. However, the new edition views intense mourning as a condition that may require psychiatric treatment. Hence, if one reads DSM-5 literally, bereavement can be viewed as pathological.

The new manual incorporates Asperger's Disorder into autism spectrum disorder. Some parents of children with this condition may worry the new categorization will cause their children to "lose" their diagnoses, and will result in a loss of educational and health-related services.

Some mental health professionals have expressed concern the new manual has spun out of control, and is now diagnosing people who formerly would have been viewed as "the worried well." They argue the expansion or "inflation" of psychiatric diagnoses will cause more people to be placed on medications that are potentially harmful, and can have a multitude of serious side effects. They believe the field of psychiatry has now expanded to encompass virtually every problem facing human beings in their lifetimes. They argue that everything has become pathologized. There's virtually no more "normal," and common "unhappiness" is now viewed as a treatable condition.

Those defending the new manual point out that some diagnoses have been eliminated or combined, while others have been added, thereby resulting in no real increase in the number of psychiatric conditions. They point out that extensive field trials were employed before revising the old manual (DSM-IV) and dispute the notion that more people will be diagnosed with mental illnesses than was formerly the case.

The DSM manual is so important because mental health professionals use it as the "bible" of the diagnostic lexicon. It defines mental illnesses in a way that can be useful, and helps determine treatments and prognoses.

Equally important is this: The manual is used by insurance companies to codify and reimburse psychiatrists, psychologists and other health care professionals for their services. Disputes over some of the new classifications are bound to arise. For instance, does a child who throws frequent temper tantrums now qualify for the new diagnosis of disruptive mood dysregulation disorder? And if treated, will health insurance reimburse the policy holder?

The manual is used extensively by attorneys in litigation to either justify or refute alleged psychiatric damages or behavior. Depending on how one views the manual, the new disorders (or elimination of old ones) can be used by either plaintiffs' attorneys, prosecutors or those representing defendants. In courtroom proceedings, attorneys will invariably use the written word, and especially the DSM manual, to buttress their own litigation agendas. The new edition will invite plenty of fireworks in many trials, civil and criminal.

According to Ronald Kessler and Philip Wang, professors of health care policy at Harvard, in the Annual Review of Public Health (2008), nearly half the U.S. population will meet the criteria for a DSM-IV diagnosis during their lifetimes. When told this rate seemed high, Kessler responded, "99.9 percent of the U.S. population has had a physical problem in their lives. There are all kinds of stuff that count as physical illness. That doesn't mean you're at death's door."

Kessler is absolutely right. Nobody objects to being labeled as having a physical condition (arthritis, hypertension, allergies or diabetes). Conversely, many people balk at being labeled with a psychiatric diagnosis. It's okay to have a diagnosis of high cholesterol, but it's a stigma to be identified as having depression, panic disorder, or a phobia.

Kessler went on to say, "Establishing psychiatric diagnoses is challenging because they rely on symptoms. It's not like you can look under a microscope."

And that's quite true: The DSM-5 manual, and all preceding it, are descriptive only. They categorize mental illnesses by observation. There are no precise biological markers, microscopic findings, or blood tests that will confirm or refute these diagnoses. Instead, they rely on judgments made by a clinician about a person's, thinking, feelings and behavior. Hence, they can sometimes be viewed as "judgmental" as though they make value statements about people. And like it or not, there is still enormous social stigma attached to being diagnosed with a mental disorder.

The bottom line is this: DSM-5 attempts to categorize symptoms and behaviors of people so clinicians are speaking the same "language" when making diagnoses. There will be some social repercussions from the changes in the new edition.

Frankly, every new version of the manual (beginning with the first edition) has had its critics. It's always been viewed by some as "cookbook psychiatry" while others have found it immensely helpful in sorting through the myriad signs and symptoms of mental and emotional disorders. There's no doubt some people with agendas will misuse the manual for their own purposes, while others will find it useful. It certainly is not a "bible," as it's often referred to in courtrooms; and it will be subject to revisions as time passes and more research is conducted.

DSM-5 will have "social side effects" that cannot be avoided given societal attitudes, our health care system, and the litigation climate in America today.

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