June 1st, 2014

DSM-5 changes: controversy continues to swirl

The release of the DSM-5 launched a firestorm of criticism over some of the added diagnoses. Two in particular – premenstrual dysphoric disorder (PMDD) and disruptive mood dysregulation (DMDD) – have generated much debate among mental health professionals.

PMDD was included in DSM-IV as depressive diagnosis not otherwise specified (NOS) and also listed in the index; the DSM-5 elevated PMDD to the front of the book. Although premenstrual syndrome (PMS) is common, the condition presents with more physical rather than mental symptoms, says Joan Chrisler, Ph.D., professor of psychology at Connecticut College, and doesn’t qualify as a diagnosable illness.

“In modern society people expect to feel good all the time. When we were more tied to the earth, we viewed change as a normal part of life. Steady state functioning is what we want now,” Chrisler says, citing pharmaceutical companies as the driving force behind some of the recent diagnoses. “Seventy percent of the time when a patient comes in and asks for a drug, they get it.” She admits that some women experience lower level dysphoria when in a premenstrual state, but the symptoms typically subside afterward.

Chrisler points out that the symptoms associated with PMDD can be applied to both genders at times. “There are quintessential differences between the sexes. Take the name ‘premenstrual’ off the diagnosis category and replace it with ‘episodic.’ Men will say they have the same symptoms,” she says.

Rather than prescribing medication – often without exploring the complaints – Chrisler suggests finding an effective coping mechanism, such as cognitive behavioral therapy or some other non-pharmaceutical approach. “It’s important to have critical thinking. [Psychologists] should focus on the patient’s complaints, look at the issues and how you can help. Reframe the situation and provide assistance and coping rather than jumping to a diagnosis,” Chrisler says. “A woman has a right to her emotions. Hormones don’t cause emotions. It would be better to deal with the source of anger and stress rather than blaming your body.”

Topping the list of the 10 most potentially harmful diagnoses is DMDD, says Allen Frances, M.D., chair of the DSM-IV task force and author of “Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma,and the Medicalization of Ordinary Life.” He reports that only one research group studied symptoms for six years prior to including the diagnosis in the new manual. “A new and untried diagnosis takes temper tantrums and medicalizes childhood,” he says.

According to Frances, the DSM-5 task force reasoned that by creating DMDD, the incidence of “careless and reckless diagnosis of childhood bipolar disorder” would be reduced. He notes that DMDD was rejected by the DSM-IV task force. “But that didn’t stop thought leaders and drug companies from widely publicizing and convincing the public that it’s a valid diagnosis,” he says. “There is an enormous excess in use of antipsychotics in children. The risk of this diagnosis may exacerbate a childhood problem.”

When diagnosing children, developmental factors must be taken into consideration, Frances says. “Be cautious and conservative in making a diagnosis. Don’t just jump to conclusions. You can’t just see the client on his worst day. He could be a different person in a week’s time,” he adds.

The National Health Interview Survey reports that more than seven percent of schoolchildren currently take medication for an emotional or behavioral problem.

Although the DSM-5 task force may have had good intentions, there may be some negative, unintended consequences, Frances says. “The American Psychological Association should be working hard to invalidate childhood bipolar disorder, not creating a new diagnosis that could cause harm,” he says. “I strongly recommend psychologists not join the bandwagon on this new, untested diagnosis.”

Eric G. Mart, Ph.D., ABPP, a forensic psychologist out of Portsmouth, N.H., reports that the decision process leading to the establishment of a diagnosis is “surprisingly informal.” He says, “There is not a lot of research involved. It could lend itself to over-diagnosis. As for DMDD, what kid doesn’t have temper tantrums?”

The bottom line is that maybe in five years there may be more solid research, emphasizes Mart. “It was premature coming up with this diagnosis.”

By Phyllis Hanlon

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