Science & Technology

Editors of Psychiatric Bible Exhibit Pseudoscientific Delusional Syndrome


The New York Times reports that the psychiatrists working on the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) have made several notable concessions to critics:

1. "Attenuated psychosis syndrome," which is not listed as a mental disorder in the current DSM, also will not be listed in the next one. Critics worried that the proposed label, intended for people who are not psychotic but might be one day, would lead to promiscuous drugging of teenagers and young adults who exhibit "delusional ideas," "perceptional abnormalities," or "disorganized speech." According to the Times, "70 percent to 80 percent of people who report having weird thoughts and odd hallucinations do not ever qualify for a full-blown diagnosis."

2. The editors also have ditched their proposed "mixed anxiety depressive disorder," which would have applied to people who exhibit "three or four symptoms of Major Depression" along with "anxious distress." The symptoms of major depression include depressed mood, lack of pleasure, weight loss, sleeping too little or too much, moving too little or too much, fatigue, feelings of worthlessness or excessive guilt, difficulty concentrating or making decisions, and recurrent thoughts of death. "Anxious distress" would have been marked by "feeling nervous & anxious," "not being able to control worrying," "having difficulty relaxing," restlessness, and "fear that something awful might happen." The Times says critics warned that the diagnosis would "unnecessarily tag millions of moderately neurotic people with a psychiatric label." The amazing part: Psychiatrists decided that was a drawback.

3. Speaking of the diagnostic criteria for major depression, the editors plan to add a caveat

The normal and expected response to an event involving significant loss (e.g, bereavement, financial ruin, natural disaster), including feelings of intense sadness, rumination about the loss, insomnia, poor appetite and weight loss, may resemble a depressive episode. The presence of symptoms such as feelings of worthlessness, suicidal ideas (as distinct from wanting to join a deceased loved one), psychomotor retardation, and severe impairment of overall function suggest the presence of a Major Depressive Episode in addition to the normal response to a significant loss.

The editors explain that "many commentators noted the previous criteria erroneously implied that bereavement could be assumed to only last 2 months," and "we wanted to correct that misunderstanding." It's not clear who supposedly misunderstood what, but the current DSM says someone who otherwise meets the criteria for major depression gets an out if he is sad about "the loss of a loved one," unless "the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation." As critics such as Gary Greenberg have pointed out, these guidelines not only put an arbitrary 60-day limit on grief; they also do not recognize other legitimate reasons for sadness. The new language is an improvement in both respects, although the label still hinges on a clinician's opinion about what counts as a "normal and expected response."

While these three changes are all intended to address concerns about overdiagnosis, another proposal—"autism spectrum disorder," which would subsume Asperger's disorder and pervasive developmental disorder as well as autism—has triggered complaints that people who need help will no longer qualify for a DSM label. Instead of backing down on that issue, the editors are insisting their changes will have hardly any impact on diagnosis, which makes you wonder why they are bothering. Public statements by advocates of the new taxonomy suggest the revisions are indeed aimed at weeding out people who wrongly think they have a mental disorder (which ought to be a mental disorder itself, if it isn't already):

In a talk on Tuesday, Dr. Susan E. Swedo, head of the panel proposing the new definition, said that many people who identify themselves as "aspies," for Asperger's syndrome, "don't actually have Asperger's disorder, much less an autism spectrum disorder."

Got that? People "don't actually have" a disorder that Swedo thinks does not actually exist—and that officially won't exist if she gets her way. If that makes no sense to you, you are probably not a psychiatrist.

More on the depression exception and the Asperger's controversy here and here.

In a recent Washington Post op-ed piece, a psychologist argues that the DSM has "an undeserved aura of scientific precision" and "should be thrown out."