x Abu Dhabi, UAEWednesday 24 January 2018

Mental illness or just personality traits?

It is the manual for many US psychiatrists and the latest edition is out this week. Yet the DSM-5 is already under attack for listing as mental disorders what others regard as just personality traits.

An executive yells at his staff - the guide could classify him as suffering from a personality disorder. Tim Pannell / Corbis
An executive yells at his staff - the guide could classify him as suffering from a personality disorder. Tim Pannell / Corbis

Be warned: if you go to bed entirely sane tomorrow evening, there is a chance that when you wake up the following morning you will be officially mad.

Wednesday sees the official publication of the long-awaited latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the guidebook to the human mind first produced by the American Psychiatric Association in 1952 and found on the shelves of psychiatrists and psychologists throughout the world.

This edition makes disturbing reading for grumpy teenagers, bad-tempered bosses, or anyone with a pile of old newspapers on their desk - they all could be exhibiting symptoms of mental illness.

More seriously, the publicity surrounding the edition has set off a worldwide debate not just about the value of classifying what many would regard as the ups and downs of life as mental disorders, but a backlash against elements of the psychiatric profession.

Last week, the Division of Clinical Psychology - the UK body that represents about 10,000 UK mental-health practitioners - attacked current psychiatric diagnosis, saying that what was "often presented as an objective statement of fact" was instead "a clinical judgment based on observation and interpretation of behaviour and self-report, and thus subject to variation and bias".

The argument has been brewing for nearly two decades. The previous edition, DSM-4, was issued in 1994 and tinkered with in 2000. DSM-5 has been 13 long, contentious years in the making.

And, say its many critics, it should come with a health warning -having your doctor read it could be seriously bad for your mental health.

Among the critics of the DSM-5 are, of course, all the usual suspects, including the Church of Scientology, whose antipathy towards the profession is enshrined in the belief that "psychiatry has repackaged [human] emotions and behaviours as 'disease' to sell drugs", and which dismisses the DSM as "psychiatry's billing bible".

But the manual is not only the object of fringe contempt, many psychiatrists and psychologists also believe that its creator, the American Psychiatric Association, is guilty of medicalising the ordinary ups and downs, quirks and foibles of human behaviour.

"If you think most diseases are established with objective criteria and rigorous debate, you'd be somewhat wrong," wrote Alan Cassels, author of the book Seeking Sickness: Medical Screening and the Misguided Hunt for Disease, in a column in March for a Canadian health magazine, Common Ground.

"The DSM has a strong track record of taking clusters of symptoms and wrapping labels around them, which lead to the accelerated use of some of the most toxic medications on the planet."

Quite extraordinarily, among the most vocal of the critics of DSM-5 is Dr Allen Frances, the psychiatrist who chaired the task force that put together the soon-to-be supplanted fourth edition of the manual and who has been waging an all-out, no-holds-barred assault on its successor publication.

DSM-5, he wrote in January in the journal Psychology Today, was set on a "mindless and irresponsible course", the result of which would be "the mislabelling of potentially millions of people with a fake mental disorder that is unsupported by science and flies in the face of common sense".

The fifth edition will include several new depressive disorders, including "premenstrual dysphoric disorder" (with symptoms of severe depression, irritability and tension) and "disruptive mood dysregulation disorder" (characterised by severe and recurrent temper outbursts, "grossly" out of proportion to the situation).

Also, "children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behavioural dyscontrol" - and think about how many teenagers you know who might fall into that category - could find themselves labelled as suffering from and, possibly, undergoing medication for "disruptive mood dysregulation disorder".

Worse, say critics, the manual will treat the perfectly normal human reaction of grief, following the loss of a loved one, as a major depressive disorder, whereas the previous edition of the manual excluded as entirely normal bereavement-linked depression that lasted less than two months.

Now, if you grieve long and hard, the profession could consider there is something wrong with you.

Meanwhile, after languishing for years under the umbrella "anxiety disorders", obsessive-compulsive disorder will now be the star of its own new category, "obsessive-compulsive and related disorders", alongside a number of brand-new conditions, including excoriation (skin-picking) disorder and hoarding disorder.

So the next time you struggle to find something in that nightmarish midden you call a loft or a garage, bear in mind that there is now "evidence for the diagnostic validity and clinical utility of a separate diagnosis of hoarding disorder, which reflects persistent difficulty discarding or parting with possessions due to a perceived need to save the items and distress associated with discarding them".

The good news is that if you work for a boss who likes to shout a lot, he or she could be the victim of an IED, or intermittent explosive disorder. In the previous edition of the manual, this diagnosis was dependent upon the presence of physical aggression. Now, "verbal aggression and non-destructive/non-injurious physical aggression" alone will do the job.

Many critics of the manual point out that it is, essentially, a redundant publication, which in large part covers the same ground covered by the World Health Organisation's International Classification of Diseases, which includes mental disorders and whose internationally agreed codes are used around the world.

In the past, says Peter Tyrer, professor of community psychiatry at Imperial College London and chair of the personality disorder group working on the revised ICD-11, due out in 2015, the ICD has "always followed DSM rather palely, because [WHO] realised they had not got the resources to do it properly and more or less just followed in its wake".

Now, he says, "there's a more sterling resistance" and in several areas the new ICD is likely to go against the DSM - and, ultimately, could make it utterly redundant.

"Personality disorder is a very good example of what I think is wrong with DSM," he says. "A lot of clever people sit around a table and say, 'I have done work on this and I want to have narcissistic personality disorder included', 'I want to have dissocial personality disorder', 'I want to have avoidant personality disorder'.

"In fact, these are categories of personality disorder that actually have no scientific basis behind them and yet here are worthy people sitting in committees all agreeing that this is important and we have got to include them."

A lot of work has been done in psychology, he says, "which has demonstrated what personality consists of, and it does not consist of a lot of diseases, it consists of a lot of personality traits".

Some disorders that previously made the grade will have been quietly pensioned off in the new edition - which might leave some patients treated under DSM-4 rules wondering why they were exposed to entire courses of drugs or other therapies.

The diagnosis of sexual aversion disorder, for example, "has been removed due to rare use and lack of supporting research" - which raises the question - if it lacked evidence, what was it doing in previous editions in the first place?

Professional antipathy towards the manual comes chiefly from members of the American Psychological Association, who generally prefer talk therapy to medication.

In a petition to the APA that has attracted more than 14,000 signatures, they say they have "substantial reservations about a number of the proposed changes", the "lowering of diagnostic thresholds" and the "introduction of disorders that may lead to inappropriate medical treatment of vulnerable populations".

But American psychiatry in general - and the manual as a consequence - has come under increasing fire for its close relationship with the drug industry.

In 2008, several years into the current cycle of manual revision, a US senator, Charles Grassley, began a series of investigations into leading psychiatrists who had pioneered the use of antipsychotic drugs in children while failing to declare millions of dollars in support from the pharmaceutical industry.

In December, the Washington Post revealed that the financial ties between the psychiatrists who were working on DSM-5 and the industry "far exceed limits recommended in 2009 by the Institute of Medicine, a branch of the National Academy of Sciences".

In one case, reported the Post, the adviser to the American Psychiatric Association who composed the justification for including bereavement as a disorder had also been the author of a 2001 study on the drug Wellbutrin, sponsored by GlaxoWellcome, which had shown that the company's antidepressant could be used to treat bereavement - a "bonanza for the drugs companies", according to the Post.

The response to the criticism came in a statement from David Kupfer, chair of the DSM-5 task force.

"While speculation is bound to occur, we think it is important to stay focused on the fact that the American Psychiatric Association has gone to great lengths to ensure that DSM-5 and the clinical practice guidelines are free from bias," he said.

He also defended the decision to "medicalise" bereavement. The removal of the exclusion "helps prevent major depression from being overlooked and facilitates the possibility of appropriate treatment, including therapy or other interventions".

Critics remain cynical.

"I have two jokes," says Prof Tyrer, "though they're not only jokes, because they are also serious [points]." The manual, he says, stands for two things: "One is Diagnosis as a Source for Money, because it brings lots of income to the American Psychiatric Association, because of all they copies they sell, whereas [the ICD] from the World Health Organisation is open-access.

"The second is Diagnosis for Simple Minds, because the big attraction of DSM is it allows a tickbox mentally, where you can say these are 'operational criteria' and if you've got two, three or four out of seven then it fact you've got the disease - which is a funny way of diagnosing in medicine."

But perhaps the heaviest blow to the prospect of there being future versions of the manual was the announcement in April by the US government's National Institute of Mental Health (NIMH) that, with its "diagnoses ... based on a consensus about clusters of clinical symptoms, not any objective laboratory measure", the book simply lacked validity.

"Patients with mental disorders," said Thomas Insel, chair of the NIMH, "deserve better".

To deliver this, NIMH has launched a decade-long Research Domain Criteria project, a "first step towards precision medicine", designed to search for biomarkers for mental illnesses and "transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system".

Undeterred, the American Psychiatric Association is taking orders now for DSM-5 and, at US$199 (Dh730 a copy), the book might be a good investment. After all, it could soon be a collector's item.