Psychiatrists Propose Revisions to Diagnosis Manual (PBS 10/2/10)
JUDY WOODRUFF: Now: rethinking mental illness.
For the first time in 16 years, the American Psychiatric Association is revising its essential dictionary, formally titled “The Diagnostic and Statistical Manual of Mental Disorders.” The book is used widely by mental health professionals to classify and diagnose illnesses. The proposed revisions have been a decade in the making, among them: a single category called autism spectrum disorders that would incorporate Asperger’s syndrome; a category called behavioral addictions, in which gambling would be the sole disorder; a risk syndromes category to help identify earlier stages of disorders like dementia and psychosis; and a recognition of binge eating disorder.
The draft has been posted online and will be reviewed and refined over the next two years.
For some perspective on the proposals and their implications, I’m joined by Dr. Alan Schatzberg. He’s president of the American Psychiatric Association. He is also chair of psychiatry at Stanford University. And Dr. Allen Frances, he’s former chief of psychiatry at the Duke University Medical Center. He led the last effort to revise the manual.
Gentlemen, thank you both for being with us.
And, Dr. Schatzberg, to you first. Why is this manual so important?
DR. ALAN SCHATZBERG, president, American Psychiatric Association: Well, it is used by — as you pointed out, Judy, by practitioners around the world to diagnose potential patients, people who come in for treatment with specific complaints, and to classify them as having one or another disorder.
It becomes the common language that mental health practitioners use to describe patients, so that we can agree on a diagnosis, very similar to cardiologists talking to an internist, saying the patient has had a myocardial infarction, or what we call a heart attack. We need to have agreed-upon diagnoses and criteria for making those diagnoses if we’re going to be able to take care of patients.
JUDY WOODRUFF: So, it’s important for doctors, obviously for the patients. Insurance companies?
DR. ALAN SCHATZBERG: Absolutely, because insurance companies will in fact pay for benefits for treatment, whether they be psychosocial, or pharmacologic, or somatic, or other forms of treatment, for specific conditions. And those conditions have to be specified somewhere.
So, just as we have the international classification of disorders for medical disorders that are used commonly by — and promulgated by the WHO, the APA, the American Psychiatric Association, has promulgated criteria and classification for mental disorder, and it started doing it in 1952.
JUDY WOODRUFF: And, just quickly, why does it need to be redone?
DR. ALAN SCHATZBERG: Because, as we study patients with particular disorders, as we understand more about genetics, about epidemiology, about brain imaging, about treatment response, about risk factors, about groupings of patients, we start to see that there are patterns that emerge, that there are disorders that are more similar to one another than we thought.
There are some disorders that we thought would be very different that we find out are really one or another variation of a common disorder. And, so, the nomenclature needs to be refined periodically.
JUDY WOODRUFF: And, Dr. Frances, now, we understand you have some concerns with what the Psychiatric Association is recommending. Tell us what those are, your main concerns.
DR. ALLEN FRANCES, former chief of psychiatry, Duke University Medical Center: Well, we learned some very, very painful lessons in doing “DSM-IV.”
We thought we were being extra careful and very conservative.
JUDY WOODRUFF: This is the last manual.
DR. ALLEN FRANCES: That’s correct.
And we thought we were being really careful about everything we did, and we wanted to discourage changes. But, inadvertently, I think we helped to trigger three false epidemics, one for autistic disorder that you mentioned, another for the childhood diagnosis of bipolar disorder, and the third for the wild overdiagnosis of attention deficit disorder.
And my concern has been that the ambitions expressed by those working on “DSM-V” would lead to unintended consequences, with many patients being created through new categories or the lowering of thresholds of existing categories, people who probably don’t need the treatment that they might receive, but would probably receive if they get a diagnosis.
JUDY WOODRUFF: So, what’s an example of something that you think may be diagnosed that shouldn’t be diagnosed?
DR. ALLEN FRANCES: Well, I think you mentioned some. Binge eating disorder is, I think, a classic example.
In order to meet the criteria for this proposed diagnosis, a person would need to binge just once a week for three months. I would certainly qualify for that. I think the estimates, the low estimates, are that this would include 6 percent of the general population.
Once a diagnosis becomes official, there’s a kind of wildfire effect, and it becomes more and more popular, especially if this is marketed as an important indication for the pharmaceutical industry. And my guess is that, before very long, maybe 10 percent of the population would qualify for this diagnosis of binge eating disorder.
That means 20 million people. And there’s no proven treatment for the condition. And, undoubtedly, lots of people would be getting unnecessary, expensive, and often harmful treatments for conditions that really are made up by the people doing the manual, without very strong support or need.
JUDY WOODRUFF: Dr. Schatzberg, how do you respond to that concern, that things are going to be diagnosed that shouldn’t be?
DR. ALAN SCHATZBERG: They’re — in fact, I think “DSM-V” has been assiduous, very careful…
JUDY WOODRUFF: And, again, this is the new — this is the acronym for this new manual.
DR. ALAN SCHATZBERG: This is the — yes, this is — the proposed criteria has been — have been very careful to define the threshold for patients being in distress, being impaired, and being able to obtain or receive a diagnosis. We try to be — refine on those criteria from “DSM-IV” to make it tighter. In fact, I think “DSM-V” will reduce the number of patients who receive diagnoses.
Now, for bulimia, I think it’s very important to point out that these patients or subjects are highly distressed. It’s not just a matter of someone overeating and having a bad meal or a bad day on Thanksgiving. In fact, these — this disorder is seen commonly in young women. It tends to be associated very commonly with obesity.
And, the last I looked, obesity is a major epidemic in this country. And if we are to in fact address and help the society deal with their obesity problems, we have to have a way of defining this pathological overeating.
JUDY WOODRUFF: Dr. Frances, you want to come back on that point?
DR. ALLEN FRANCES: Well, just quickly, obesity is certainly the largest public health problem facing Americans, but that doesn’t mean it’s a mental disorder.
JUDY WOODRUFF: And, Dr. Frances, broaden this out. I mean, clearly, there are specific concerns you have. But — but, more broadly, why should we be concerned, whether it’s young people, attention deficit, which is what you said happened with the previous manual, or any of these diagnoses going forward? What’s the real concern here?
DR. ALLEN FRANCES: Well, with attention deficit disorder as an example, the prescription of stimulants has exploded.
And what’s happened is that, often, these are given, not for a mental disorder, but for performance enhancement. And getting a diagnosis of attention deficit disorder allows you to get that stimulant treatment, which, for many people, may not be for a mental disorder, but may just be so that they can do better in their everyday lives.
Thirty percent of college students use stimulants to do better at school.
JUDY WOODRUFF: You want to re…
DR. ALLEN FRANCES: And this also creates — it also creates a secondary, illegal market that the prescription drugs are sold on, so that there is a huge public health, I think, significance in this, as well as a societal problem that’s been caused by it.
JUDY WOODRUFF: A huge public health concern, Dr. Schatzberg?
DR. ALAN SCHATZBERG: Well, certainly, they’re — we don’t want to have overuse of stimulants or performance-enhancing drugs. But just having a diagnosis doesn’t mean that, in fact, that leads to it.
In fact, that is a whole social kind of question about how best to treat individuals with attention deficit disorder. But those individuals who are using stimulants, potentially illegally or illicitly, are not doing it because they have a psychiatric diagnosis. They’re using it for their own performance enhancement. And it’s just as — having a diagnosis of attention deficit disorder doesn’t lead to potential necessarily performance enhancement.
JUDY WOODRUFF: Just…
DR. ALAN SCHATZBERG: That’s kind of a silly argument, from my end.
JUDY WOODRUFF: Just — well, just quickly, what — where do we go from here, Dr. Frances? This — we — as we said, there are two years now before this is finalized. What would you look to see happen, Dr. Frances, in just a few words?
DR. ALLEN FRANCES: Well, I think the process to date has been way too secretive and closed to external influence. It should be opened up.
I think there needs to be a very, very careful forensic review, because unintended consequences in forensics can be a huge problem. I think there needs to be a risk-benefit analysis of each of the new suggestions to make sure they do, indeed, make sense.
And I think the field trials that will be coming up soon need to be exposed to public review before they begin.
JUDY WOODRUFF: And, Dr. Schatzberg, in a few words, will all those things happen?
R. ALAN SCHATZBERG: Well, you know, the task force will take in the comments on the public posting. I think this is an incredible example of openness and transparency.
The field trials will, in fact, test out whether these proposed kinds of categories make sense, and they make — and whether they make sense from a diagnostic end, as well as from a sociologic end. So, we will try to address some of these issues.
JUDY WOODRUFF: It’s “The Diagnostic and Statistical Manual of Mental Disorders.”
And, gentlemen, we thank you both for being with us, Dr. Alan Schatzberg, Dr. Allen Frances. Thank you.
DR. ALAN SCHATZBERG: Thank you, Judy.
DR. ALLEN FRANCES: Thank you.