"Where are we going to put the narcissists?"
It was a question asked urgently by one of the hundreds of psychiatrists gathered here last week for their professional society's annual meeting. With doctors in the thick of a years-long effort to rewrite the essential textbook for diagnosing mental illnesses, questions like these came up time and again in meeting rooms, over drinks sipped from coconut shells, and in other venues during the five-day conference.
Among the myriad proposals now on the table: reducing the number of specific personality disorders from 10 to five, a move that would eliminate the diagnosis of narcissistic disorder.
"Of course there are narcissists!" the psychiatrist insisted in the convention's vast exhibit hall, where new research papers were displayed next to pharmaceutical-industry booths. "We see them all the time!"
Don't let the cheery Hawaiian shirts fool you — the nation's psychiatrists aren't feeling all that ku'u aku (relaxed) as the deadline nears for the next edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5.
The first revision in almost 20 years will roll off the presses in 2013. Since the 1994 edition, research has exposed pieces of the biological framework underlying disorders like schizophrenia, anorexia and depression. But molecular tests and brain scans based on those discoveries aren't yet ready for diagnostic use, and that leaves the authors of the upcoming book with the same problem that vexed their predecessors: how to distinguish a mental illness from the rainbow of normal human behavior.
Much of the discussion at the American Psychiatric Assn. meeting centered on fears that, without solid scientific evidence, additions or deletions in their new bible of mental health could do more harm than good.
"The brain is so darn complicated," said Dr. David Axelson, director of the Child and Adolescent Bipolar Services program at the Western Psychiatric Institute in Pittsburgh.
As with each edition, the controversies dogging DSM-5 center on the proposed "new" conditions. Among the questions:
• Is there a distinct mood disorder that occurs in some women prior to their periods?
• Is hoarding a brain-based illness?
• Can the sorrow accompanying bereavement swell into a certifiable mental disorder?
Even when concepts are not at issue, nomenclature sometimes is. Suggestions include replacing the word "anxiety" with "worry," and scrapping the terms "addiction," "dependence" and "substance abuse" in favor of "substance-use disorder."
"We have to be very careful about our choice of language and precise criteria," said Dr. David J. Kupfer, the DSM-5 task force chairman and director of research at Western Psychiatric Institute and Clinic. Slight word changes could translate into making a disorder much more prevalent — or much more rare, he said.
Other sticking points center on what may be dropped from the book, such as narcissistic disorder.
In one session on a balmy Sunday morning, Thomas Widiger, a psychologist and expert on personality disorders at the University of Kentucky, warned his colleagues that "it's the beginning of the end for these diagnoses as personality disorders."
In another room, doctors debated whether a patient must have impaired function — such as problems in personal relationships — to qualify as having a mental disorder. "If your life is humming along just fine despite gambling 30 hours a week, do you really have a gambling addiction?" one psychiatrist asked with a note of exasperation in his voice.
Yes, a colleague responded: "The person just doesn't know he has a problem yet."
Although the DSM began as a slender guidebook for the U.S. Armed Forces in 1952, its significance has soared as research blurs the lines between physical and mental conditions.
Fields like neurology and psychiatry are drifting ever closer, Kupfer notes. While neurologists struggle with defining the early signs of Alzheimer's disease, psychiatrists are mulling a proposal to list "mild neurocognitive disorder" in DSM-5.
Even obesity, one of the major health problems of the era, has aspects that relate to behavioral health. One new proposal for DSM-5 is to add a diagnosis of "binge eating disorder."
Inclusion in the DSM can legitimize mental problems, leading to insurance coverage for treatments and perhaps more compassionate public attitudes.
"The DSM doesn't just have medical implications; it has economic and legal implications," said Dr. Jan Fawcett, chairman of the mood disorders work group for DSM-5 and a psychiatrist at the University of New Mexico School of Medicine.
And it can backfire. A minor wording change in the last DSM revision prompted attempts to label repeat sex offenders as people stricken with the mental disorder paraphilia, blurring the line between criminal behavior and mental illness, said Dr. Allen Frances, chairman of the DSM-IV Task Force and one of the most vocal critics of DSM-5.
Allen says the many advances in neuroscience, brain imaging and molecular biology have yielded valuable information about the workings of the human brain but not enough to make psychiatric diagnoses. Thus, he said, there is little to be gained by changing the DSM now.
"The experts are well-meaning — each suggestion made has the goal of identifying patients currently missed," Frances said. But, he added, "none of the changes can accurately identify patients who are in real need of help from normal people with everyday problems who would be better left alone."
Other psychiatrists have pointed criticisms of DSM-5 as well. Dr. Helen Lavretsky, a geriatric psychiatrist at Ronald Reagan UCLA Medical Center, said she was concerned about the proposed diagnosis of "mild neurocognitive disorder" and whether there are enough reliable criteria to diagnose it. She volunteered to help with a DSM-5 field trial to test the concept.
In addition to conducting field trials for some proposed changes, the DSM organizers are widely praised for creating a transparent editing process. Suggested changes are posted online on DSM5.org. And the second of three public comment periods — whereby anyone can submit feedback on the book — began this month and runs through June 15.
The final product, which will be hammered out over the next 18 months, will contain no surprises, Kupfer said.
"People will be familiar with what we're doing," he said.