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