Is the compulsion to hoard things a mental disorder? How about the practice of eating excessively at night?
And what of Internet addiction: Should it be diagnosed and treated?
As the clock ticks toward the release of the most influential of mental health textbooks, psychiatrists are asking themselves thousands of complex and sometimes controversial questions.
The answers will determine how Americans’ mental health is assessed, diagnosed and treated.
Over the next 18 months, psychiatrists will hammer out a draft of the fifth edition of the American Psychiatric Assn.'s Diagnostic and Statistical Manual of Mental Disorders, more commonly called DSM-V. Nowhere have the discussions been more heated, the ramifications most vividly foretold, than here at the organization’s annual meeting.
Some psychiatrists warn that the tome runs the risk of medicalizing the normal range of human behaviors; others vehemently argue that it must be broad enough to guide treatment of those who need it.
But all agree that the so-called bible of psychiatry is expected to be considerably more nuanced and science-based than the last edition, DSM-IV, published in 1994.
Brain imaging and other technologies, plus new knowledge on biological and genetic causes of many disorders, have almost guaranteed significant alterations in how many mental afflictions are described.
“There are no constraints on the degree of change,” said Dr. David J. Kupfer, chairman of the DSM-V task force and a psychiatrist at the University of Pittsburgh’s Western Psychiatric Institute and Clinic.
The book will describe disorders in more detail, acknowledge variations that haven’t been viewed as part of “classic” illness and explain how conditions differ based on age, race, gender, culture and physical health, Kupfer said.
Planning on the text began almost a decade ago, and leaders delivered a progress report to their colleagues last week. They emphasized that the book, slated for publication in 2012, should better reflect the lives and complexities of real people, not simply the most severe cases or most cut-and-dried diagnoses.
Critics of the current edition -- and there are many -- say that it allows for diagnosis only after a dramatic threshold has been reached.
“We are really hoping we’ll be able to improve things,” Kupfer said. “And that will help us do a better job of taking care of our patients.”
Used around the world and available in 13 languages, the book has evolved from its humble origins in 1952 as a dry collection of statistics on psychiatric hospitalization. It is now used by not just psychiatrists, but internists, family practitioners, psychologists, social workers, courts and education professionals to guide the diagnosis and therapy for a host of mental and behavioral conditions. More than 1 million copies of DSM-IV have been sold.
Having a DSM diagnosis can mean an autistic child will get services from the public school system or that an adult is covered by workplace anti-discrimination laws.
For health insurance companies, it has become a basis for decisions on paying for care.
Some have questioned whether those writing the new book may be influenced by the pharmaceutical industry. Over the last two decades more medications have become available to treat mental disorders, and some doctors worry that the text may be written in a way that expands the market for drug therapies.
A study published online in the current issue of the journal Psychotherapy and Psychosomatics found that of 20 work group members writing clinical practice guidelines for the treatment of bipolar disorder, schizophrenia and major depression, 18 had at least one financial tie to industry.
A commentary in the May 7 New England Journal of Medicine said that 56% of DSM-V task force and committee members have industry ties.
DSM-V committee members have been asked to abide by conflict-of-interest rules, including agreeing to receive no more than $10,000 annually from industry sources during the period they serve on the committee.
But that isn’t going far enough, said Lisa Cosgrove, lead author of the Psychotherapy and Psychosomatics analysis and an associate professor and clinical psychologist at the University of Massachusetts. “There are currently work groups where every single person has ties,” Cosgrove said. “It doesn’t seem like genuine progress has been made.”
Regardless of the potential pitfalls of the upcoming edition, mental health professionals say, the current DSM doesn’t always describe the people they are seeing, those with more than one disorder, a less-severe version of a disorder or one clearly diagnosable disorder but hints of other problems.
“In reality, there are a lot of shades of gray,” said Dr. William E. Narrow, research director of the DSM-V task force.
The new version will help doctors craft more complex assessments. A person may meet the criteria of having depression, for example, but may also exhibit elements of anxiety or impulsiveness.
Also, mood disorders range widely from mild to severe, said Dr. Jan Fawcett, chairman of the mood disorders work group, one of 13 committees on the task force. A person with four of the nine listed symptoms for depressive disorder can be more troubled and disabled than another person with six of the nine symptoms.
“We don’t want to take everyone who is demoralized by life and call it depression,” he said. “But we also don’t want to miss something.”
Attention to finer shades will also help doctors and therapists recognize disorders in their earliest stages, when they are mild and easier to treat or prevent. Psychiatrists are especially interested in identifying prodromal forms, or earliest symptoms, of conditions such as bipolar disorder, schizophrenia and dementia, said Dr. William Carpenter Jr., psychiatry professor at the University of Maryland and chairman of the psychotic disorders work group.
Other changes simply reflect modern times, with obesity, for example, potentially to be labeled as a symptom of, or risk factor for, a mental disorder. This, among other things, may help doctors address a growing controversy on whether candidates for bariatric surgery are being adequately screened for their psychological health before they undergo the procedure.
“We know obesity is a risk factor for physical disorders and is probably a risk factor for psychiatric disorders too,” Kupfer said. “The work group has spent time on what to do with obesity in DSM-V.”
Gambling, sex addiction and Internet addiction -- formerly dismissed as harmful habits that could be defeated with willpower -- may also be labeled illnesses.
“It isn’t a question of whether these things are real,” Kupfer said. “They are. The question is whether there is enough empirical evidence to meet the threshold.”
Leaders of the APA acknowledge the controversial nature of some of their discussions and have posted recent progress reports on the association’s website, www.dsm5.org.
The meeting may have ended Thursday, but debates, revisions and studies are slated to last for 18 more months. And the new edition won’t land on psychiatrists’ desks with a note saying, “See you in 15 years.” Task force members say it will be updated frequently.