Entries in DSM-5 (3)


Guidelines for Diagnosing Psychiatric Disorder May Overlook Physical Illnesses 

Keith Brofsky/Thinkstock(NEW YORK) -- The addition of a newly-labeled psychiatric disorder called somatic symptom disorder to the Diagnostics and Standards Manual, or DSM-5, has fueled a debate among patients and advocacy groups who fear that broader and "looser" criteria may make it easier for doctors to dismiss patients as mentally ill when in fact they have a physical illness.

Somatic (or bodily) symptom disorder or SSD is characterized by symptoms that suggest physical illness or injury that are either "very distressing" or result in disruption in a person's functioning. The symptoms are also often accompanied by "excessive and disproportionate thoughts, feelings and behaviors," according to the American Psychiatric Association.

Critics worry that patients will be misdiagnosed as mentally ill and won't get treatment, affecting mostly those with chronic and difficult to diagnose neurological disorders and multi-system diseases like ME/CFS, ones that are poorly understood and can take years to get medical answers.

"A lot of people will be written off as crocks -- it's just in their head," said Dr. Allen Frances, who was chair of the task force that created the DSM-4 and professor emeritus of psychiatry at Duke University. "They won't get the medical work-up they need. A lot of times they diagnose it as depression and anxiety and they get stigmatized."

But Dr. Joel E. Dimsdale, chair of the committee that reviewed the SSD diagnosis and professor emeritus in psychiatry at University of California, San Diego disagrees, noting that the new SSD diagnosis replaces four somatic disorders that were "confusing" and rarely used by doctors.

The goal was to simplify the diagnosis, according to Dimsdale. One older diagnosis, somatization disorder, had a checklist of 37 symptoms and was modified three times. "Doctors throw up their hands and can't even keep the stuff straight," he said.

But critics like Frances argue the new diagnosis could "mislabel" 1 in 6 people with cancer and heart disease; 1 in 4 with chronic pain and irritable bowel; and will have an astounding false positive rate of 7 percent in the general population, based on projections from the DSM-5 working groups.

"I think they have gone overboard," said Frances.

Frances is worried about people like Bridget Mildon, a 36-year-old mother of three from Salmon, Idaho, who said she was misdiagnosed with "conversion disorder," an older classification of somatic disorder, when she actually had a rare neurovascular disorder that causes transient seizures or full-blown stroke.

"It took me almost five years to get a doctor to finally reevaluate and look at my symptoms from a different perspective," Mildon said.

But Dimsdale defends the updated DSM, which he said is more "patient friendly" than the older DSM-4, which was written 20 years ago.

“I see it as a useful working guide to help doctors diagnose and treat patients. If it doesn't work, we'll fix it in the DSM-5.1 or DSM-6," said Dimsdale. "Perhaps some people fear they will be labeled or mislabeled, but my perspective is that it's important to treat people who are suffering," he said. "That's what we are about."

Copyright 2013 ABC News Radio


Hypersexuality Disorder in Line to Become a Mental Diagnosis

Courtesy Candy Cane(NEW YORK) -- He goes by the online name Candy Cane, and his sexual urges have taken over his life, escalating exponentially each day.

Married and the father of five children, the 51-year-old spends more than six hours a day Internet video-chatting, taking photos of himself and seeking out male and female partners.

Candy, a retired combat medic who lives in the Southwest, said he has survived two military conflicts, but nothing has been as challenging as fighting his addiction to sex.

"I have become reckless and uncaring about losing anything," said Candy, who was too embarrassed to use his real name.  "I care more about my sexual urges than my family right now."

"I am losing control and I am going to end up with an STD or AIDS," he said.

Candy exhibits all the symptoms of hypersexuality disorder, a proposed medical diagnosis that psychiatrists hope will be part of the DSM-5, the latest version of the Diagnostic and Statistical Manual of Mental Disorders.

Dr. Martin Kafka, an associate professor at Harvard Medical School who is the primary author of the revisions to the DSM, said proponents hope the DSM listing would open the door to more research that might help people like Candy.

"If you review the empirical research literature in the last 20 years from a variety of perspectives, it looks at the problem and calls it by different names, but all of these names have a lot in common when describing the same phenomenon," said Kafka.

If approved, hypersexuality disorder will be defined as exhibiting repetitive, intense sexual fantasies, urges and behavior in association with the following criteria in adults:

  • excessive time consumed planning and engaging in sex -- in response to a dysphoric mood state like anxiety, depression, boredom and irritability;
  • in response to stressful life events; and
  • unsuccessful efforts to control or reduce such urges, disregarding risk for physical or emotional harm to self or others.

The behavior must also cause "clinically significant distress or impairment" in a person's daily personal or work life.

"If this problem gets to the point where you are being labeled as a philanderer or a scoundrel or a nasty narcissist, and it happens there is a label of hypersexuality disorder that does validly describe the nature of your behavior, one possibility is reframing the problem and getting medical treatment," Kafka added.

But Dr. Allen Frances, professor emeritus of psychiatry and behavioral sciences at Duke University in Durham, N.C., said the proposal is "a really stupid idea" that might lead those who misbehave to cry, 'It's not my fault.'"

"There may be some very small percentage of people who could qualify for addiction to sex, but if it ever became a diagnosis, it would be wildly misapplied," he said.  "Addiction implies that you keep doing it when there is no more pleasure and it causes harm.  It becomes an excuse to misbehave."

Frances, who worked on the DSM-4, argues that too many "normal behaviors" have been viewed as illness.

"Medicalizing this sort of misbehavior is reducing personal responsibility and acting like there is a medical solution," he said.  "There is very little scientific evidence and the boundaries are fuzzy."

Kafka admits that there is more clinical than scientific data on sexual hyperactivity, but including it as a disorder in the DSM-5 will open doors to that kind of research.

"By calling it an illness, you could be quite relieved that for something you have not really been able to control on your own, help is available," he said.

Copyright 2012 ABC News Radio


Mental Health 'Bible' Criticized for Financial Conflicts of Interest

Stockbyte/Thinkstock(BOSTON) -- Controversy continues to swell around the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, better known as DSM-5. A new study suggests the 900-page bible of mental health, scheduled for publication in May 2013, is ripe with financial conflicts of interest.

The manual, published by the American Psychiatric Association, details the diagnostic criteria and recommended treatments -- many of which are pharmacological -- for each and every psychiatric disorder. After the 1994 release of DSM-4, the APA instituted a policy requiring expert advisors to disclose drug industry ties. But the move toward transparency did little to cut down on conflicts, with nearly 70 percent of DSM-5 panel members reporting financial relationships with pharmaceutical companies -- up from 57 percent for DSM-4.

"Organizations like the APA have embraced transparency too quickly as the solution," said Lisa Cosgrove, associate professor of clinical psychology at the University of Massachusetts-Boston and lead author of the study published Tuesday in the journal PLoS Medicine. "Our data show that transparency has not changed the dynamic."

The DSM is developed by APA-appointed panels consisting of experts in various fields of psychiatry. But many of these experts serve as paid spokespeople or scientific advisors for drug companies, or conduct industry-funded research. Some of most conflicted panels are those for which drugs represent the first line of treatment, with two-thirds of the mood disorders panel, 83 percent of the psychotic disorders panel and 100 percent of the sleep disorders panel disclosing "ties to the pharmaceutical companies that manufacture the medications used to treat these disorders or to companies that service the pharmaceutical industry," according to the study.

"We're not trying to say there's some Machiavellian plot to bias the psychiatric taxonomy," said Cosgrove, who is also a research fellow at Harvard's Edmond J. Safra Center for Ethics. "But transparency alone cannot mitigate unintentional bias and the appearance of bias, which impact scientific integrity and public trust."

The DSM-5 has also drawn criticism for introducing new diagnoses that some experts argue lack scientific evidence. Dr. Allen Frances, who chaired the revisions committee for DSM-4, said the new additions would "radically and recklessly" expand the boundaries of psychiatry.

"They're at the boundary of normality," said Frances, who is professor emeritus of psychiatry at Duke University. "And these days, most diagnostic decisions are not made by psychiatrists trained to distinguish between the two. Most are made by primary care doctors who see a patient for about seven minutes and write a prescription."

Under the new criteria, grief after the loss of a loved one, mild memory loss in the elderly and frequent temper tantrums in kids would constitute psychiatric disorders. An online petition challenging the proposed changes, which would label millions more Americans as mentally ill, has accrued more than 12,000 signatures.

"We're not opposed to the proper use of psychiatric drugs when there's a real diagnosis and when a child or an adult needs pharmacological intervention," said David Elkins, president of the American Psychological Association's society for humanistic psychology and chairman of the committee behind the petition. "But we are concerned about the normal kids and elderly people who are going to be diagnosed with these disorders and treated with psychiatric drugs. We think that's very, very dangerous."

Elkin said he's "dismayed" that seven in 10 panel members has ties to drug companies.

APA medical director and CEO Dr. James Scully insisted the DSM-5 development process "is the most open and transparent of any previous edition of the DSM."

"We wanted to include a wide variety of scientists and researchers with a range of expertise and viewpoints in the DSM-5 process. Excluding everyone with direct or indirect funding from the industry would unreasonably limit the participation of leading mental health experts in the DSM-5 development process," he said in a statement.

Cosgrove said she believes there are plenty mental health professionals with no financial ties to drug companies. If necessary, experts with conflicts could still participate in the process as non-voting advisors, she said.

Copyright 2012 ABC News Radio

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