Australian psychiatrists have welcomed a rare move by a US panel editing the universal diagnostic manual to drop two unpopular proposals for new diagnoses of psychotic or depressive disorders.
The decision to back away from a proposed diagnosis of “attenuated psychosis syndrome” – for people at risk of developing psychosis, and from “mixed anxiety depressive disorder” – for people with a mixed state of both illnesses, was a welcome respite from the relentless push to expand the boundaries of pathology, experts said.
The American Psychiatric Association panel in charge of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) also modified the definition of depression to ensure that people experiencing normal grief over the death of a family member or a job loss would not be included.
Professor Gordon Parker, Scentia Professor in the School of Psychiatry at the University of New South Wales, said there had been “great concern in the community over the past 10 years in particular about what you could call ‘psychiatric imperialism’ – where the boundaries of categorising psychiatric disorders has moved from the clearly pathological down into the more normal. There’s that background concern that does need to be respected.”
Professor Parker cited the case of the late Australian novelist Bert Facey, author of A Fortunate Life: “Here was a man who had grown up with the most terrible deprivation right through his life, who had marched on with Herculean resilience. But the one thing he said he would never fully recover from was the death of his son in the war. I think there are certain circumstances where people never recover from grief, and I think that’s normal. So to call grief a psychiatric illness just because it lasts longer than a certain period is really risky.”
Critics of the DSM said the proposed diagnosis of “attenuated psychosis syndrome” would encourage psychiatrists to prescribe drug treatment for young people who did not need it.
“Recent studies show that the capacity to predict who will convert from showing what looks like being psychosis prone to actually having it is virtually zilch,” Professor Parker said. “If that is true, and it has been shown in a few studies for psychoses such as schizophrenia, if we can’t predict those who are at risk, then it’s very dangerous to go in and prescribe medications.”
“Mixed anxiety depressive disorder”, meanwhile, would capture people who showed signs of both but who did not satisfy the threshold of either illness on its own. This could stigmatise millions of mildly neurotic people with a psychiatric label.
Jon Jureidini, Professor of Psychiatry at University of Adelaide, said that the DSM occupied a place in society that was “just not legitimate. The history of DSM is that every time it’s updated, there are several new diagnoses added, and as a result the number of people considered to have a psychiatric condition expands enormously.
"We’re not just pathologising normal behaviour, we’re also pathologising abnormal behaviour that should not be regarded as typical of a psychiatric illness.”
There were other consequences, he said. People unnecessarily diagnosed with a psychiatric disorder might not be able to apply for income protection insurance or travel insurance.
Allen Frances, a former panel chairman and Emeritus Professor at Duke University, has been one of the most vocal critics of the DSM. “We have dodged bullets on Psychosis Risk and Mixed Anxiety Disorder,” he wrote in a recent online posting. But DSM 5 was “still a mess” he said. The revisions should be “just the first step in a systematic program of reform - a prelude to all the other changes needed before [it] can become a safe and scientifically sound document.”
But the DSM also served an essential purpose, said Professor Jayashri Kulkarni, from the Central and Eastern Clinical School at the Monash Alfred Psychiatry Research Centre: “At the heart of it is a burning need for classification definitions to base diagnoses and research on. As a psychiatry researcher, I cannot begin to conduct investigative biological tests to develop new treatments for a mental illness unless there are a standardised set of symptoms to use as the basis for research.”
Psychiatry needed the 5th edition of the DSM to be as “watertight” as possible, to permit better research, which in turn would allow for better treatment for people with mental illnesses, she said. “In the end, a global view of DSM 5, notwithstanding the inevitable border skirmishes, is reasonable, and will assist the field to move forward. And about time – as we head into a future where depression is rife, dementia looms large and we are not winning the street drugs and alcohol abuse battle.
"DSM is the system we love to hate, but have to have.”