Issue 14 / 5 October 2010

IS COMPROMISE always a good thing? No, especially in a committee setting.

Take the committees responsible for revising the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the most influential document on psychiatric practice worldwide.

There are many examples of poor decision making here, some of which have been highlighted by Professor Allen Frances, who chaired the DSM-IV Task Force.

The draft document for DSM-5, released this year, includes a suggestion to remove the bereavement exclusion for major depression, thereby converting grief after losing a loved one into a mental disorder.

And then there are the well documented dangers of creating a category of “psychosis risk syndrome” (now relabelled “attenuated psychotic symptoms syndrome”).

Despite the name change, it is just as perilous.

The diagnosis seeks to identify young people at risk of psychosis, but most experts agree this would be stigmatising, prone to misdiagnosis and could result in unnecessary prescriptions for potentially dangerous antipsychotic medication.

But my favourite example of the absurdities that can arise from compromise is that DSM-5 could feature a new category: “temper dysregulation disorder with dysphoria” (TDD).

This “disorder” is characterised by three or more episodes a week of “severe recurrent temper outbursts in response to common stressors” in more than one setting.

This angry episode should be developmentally inappropriate and “grossly out of proportion in intensity or duration to the situation or provocation”, and accompanied by observable “persistently negative” mood, according to the proposed revision.

This is the problem: TDD has only been created in response to the marked upsurge in the diagnosis of paediatric bipolar disorder in the United States.

The committee even acknowledges that there is little research on TDD and they also raise the concern that the diagnosis of TDD will become prematurely reified.

However, the committee says it hopes the availability of TDD as a diagnosis will prevent a substantial number of youth who do not actually meet criteria for paediatric bipolar disorder from being diagnosed with it.

What the committee has actually done is shirk the decision on whether to extend the diagnostic criteria of paediatric bipolar disorder beyond the established criteria — even though the evidence is pretty clear that they should not be extended.

The DSM-5 is due to be finalised in 2013. My advice to the committee is this: acknowledge that children’s disruptive and dangerous behaviour will only very rarely be driven by bipolar disorder.

Much more often it is a non-specific signal that the child is in some predicament that exceeds his or her coping skills.

What is required is a thorough and sensitive attempt to understand the context and meaning of the behaviour, rather than labelling or medicating it.

As happens in many committees, they have favoured lame compromise over brave decision making.

Dr Jureidini is a child psychiatrist and head of the Department of Psychological Medicine, Women’s and Children’s Hospital, Adelaide. He is a Senior Research Fellow, Department of Philosophy, Flinders University and an Associate Professor in Psychiatry and Paediatrics, University of Adelaide. He is a spokesman for Healthy Skepticism Inc, an organisation devoted to countering misleading drug promotion.

Posted 5 October 2010

4 thoughts on “Jon Jureidini: DSM-5 — dodgy decisions and disorders

  1. Dr Joe says:

    Well said.Let kids be kids. If we do not like their behaviour then they need parenting and boundaries not labels and drugs.

  2. CB says:

    well put, thank you;the medical profession needs to avoid these very dubious diagnoses, or we will end up in a mess and with an even worse reputation amongst the scientologists too!

  3. Sue Ieraci says:

    Very well-put and relevant. It’s important to understand the range of incentives driving this need for a medical label for every behavioural problem. Of course the pharmaceutical companies are in there, but that’s not all. A medical label also entitles parents and families to all sorts of help and support that might not be available if their child were labelled “naughty” rather than sick. In some ways, it might also help distract people from a judgemental approach into a more analytical one (which may be good), but then the analysis needs to be behavioural, not medical.

  4. Dr Kim Lowe says:

    Like any document, it is composed by people. The DSM IV has its limitations as will the DSM V. The Manual is a guide. It will be wrong in places. It will often not describe or accurately label the mental health issue of a particular patient. The danger I see is that doctors and psychologists often proceed with a treatment regimen suggested for the ‘label’ when this treatment will be of little benefit as the patient’s condition is not really definable under the label. It surprises me that well qualified psychological therapists can be so limited by believing the label and all it implies and acting without further thought.
    Lawyers like to write documents, pat themselves on the back for their efforts as it seems to cover all aspects needed, and THEN actually believe that it is incontrovertibly true in every detail. It is nonsense of course. We, as medical practitioners need not be so naïve.
    The DSM V should be an improvement in what we have, but it will have deficiencies. Hopefully some of these can be rectified before we are condemned to its effects.

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