Internet addiction, shyness, defiance and grief on bereavement could be mental disorders – Debate on proposed DSM-5

The American Psychiatric Association (APA) has attracted a lot of debate on its proposed amendments to its newest Diagnostic and Statistical Manual of Mental Disorders (DSM) the outlines psychiatric symptoms in the mental-health industry.

Opponents say the new version would label millions more people as “mentally ill” for conditions such as extreme shyness - and qualify them for psychiatric drugs they don't need. “[It's] hard to avoid the conclusion that DSM-5 will help the interests of the drug companies,” said Allen Frances of Duke University, according to Reuters.

DSM-5 (previously known as DSM-V) is the planned fifth edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders. It is due for publication in May 2013 and will supersede the DSM-IV which was last revised in 2000. APA has an official development website for posting of draft versions of the DSM-5.

The DSM-5, as the new edition will be called, is scheduled to be released in May 2013, and could list “Internet addiction” among its diagnoses. The association says it is still considering how to address non-substance-abuse addictions. “Gambling disorder has been moved into this category and there are other addiction-like behavioral disorders such as ‘Internet addiction’ that will be considered as potential addictions to this category as research data accumulate,” the APA says on its website.

Experts say lots of the new diagnoses are problematic - like “oppositional defiant disorder.” “That basically means children who say 'no' to their parents more than a certain number of times,” said Pete Kinderman of Liverpool University's Institute of Psychology, according to Reuters. “On that criteria, many of us would have to say our children are mentally ill,” he said. People who are excessively shy could also be diagnosed as mentally ill under the new guidelines, Kinderman said. Kids' temper tantrums might be explained by “disruptive mood disregulation disorder,” characterized by temper outbursts that occur at least three times per week.

Loneliness could attract a diagnosis of chronic depressive disorder, and so could unhappiness following bereavement. A serial rapist could be classified as mentally ill, given a diagnosis of paraphilic coercive disorder. The diagnostic approach, a tick-box list of symptoms leading to a label, was always “hugely problematic”, Kinderman said. He also disagreed with the label of paraphilic coercive disorder: “In my view, rape is a crime and should not necessarily be regarded as a disorder. It gives people an excuse for that behavior,” he said.

David Elkins, president of the American Psychological Association's society for humanistic psychology, helped launch a petition against the new manual, yielding more than 11,000 supporters, according to ABC News. “Our main concern is that they've introduced some new disorders that have never been in a DSM before that we think are not scientifically based,” he said. “We're not opposed to the proper use of psychiatric drugs when there's a real diagnosis and when a child or an adult needs pharmacological interventions,” he said. “But we are concerned about the normal kids and elderly people who are going to be diagnosed with these disorders and treated with psychiatric drugs. We think that's very, very dangerous.”

Dr. Allen Frances, who worked on revisions for the current manual, DSM-4, agrees that the proposed changes are irresponsible. “You don't want to be inventing new diagnoses until you're sure they can be accurately made, effectively treated that the treatments are safe,” said Frances, a psychiatry professor at Duke University, according to ABC News. “None of these conditions is fulfilled in DSM-5. You can't have one professional organization, like the American Psychiatric Association, responsible for vetting something so important,” he added.

Richard Bentall, chair of clinical psychology at the University of Bangor, said, “Like earlier editions, this version of the manual is not based on coherent research into the causes or nature of mental illness. It seems likely that the main beneficiaries will be mental health practitioners seeking to justify expanding practices, and pharmaceutical companies looking for new markets for their products.”

Dr Lucy Johnstone, a consultant clinical psychologist, at Cwm Taf Health Board, said, “DSM and the proposed revisions are based on the assumption that mental distress is best understood as an illness, mainly caused by genetic or biochemical factors. It is important to realize, with the exception of a few conditions such as dementia, there is no firm evidence to support this. On the contrary, the strongest evidence is about psychological and social factors such as trauma, loss, poverty and discrimination. In other words, even the more extreme forms of distress are ultimately a response to life problems. We need a paradigm shift in the way we understand mental health problems. DSM cannot be reformed – it is based on fundamentally wrong principles and should be abandoned.”

Til Wykes, professor of clinical psychology at Kings College London, said, “The proposals in DSM-5 are likely to shrink the pool of normality to a puddle with more and more people being given a diagnosis of mental illness.”

Professor Nick Craddock, consultant psychiatrist in Cardiff and director of Wales' National Centre for Mental Health, said, “Somebody who is bereaved might need help and even counseling, but they did not need a label saying they had a mental illness. I believe that a large proportion of psychiatrists in the UK and Europe are skeptical about DSM-5.”

Simon Wessely, of the Institute of Psychiatry, King’s College, London, said, “We need to be very careful before further broadening the boundaries of illness and disorder. Back in 1840 the census of the United States included just one category for mental disorder. By 1917 the American Psychiatric Association recognised 59, rising to 128 in 1959, 227 in 1980, and 347 in the last revision. Do we really need all these labels?” “Probably not. And there is a real danger that shyness will become social phobia, bookish kids labeled as Asperger’s and so on.”

The APA hasn't commented on the backlash, but said in a statement that it considers “input from all sectors of the mental health community a vital part of the process,” according to ABC News. In response to criticism from the British Psychological Association last year, Darrel Regier, vice-chair of the DSM-5 task force wrote, “While we agree that human feelings and behaviors exist on a spectrum that contains some overlap of normal reactions to disease states, psychiatry also recognizes that there are real and discrete disorders of the brain that cause mental disorders and that can benefit from treatment.”

Dr. Ananya Mandal

Written by

Dr. Ananya Mandal

Dr. Ananya Mandal is a doctor by profession, lecturer by vocation and a medical writer by passion. She specialized in Clinical Pharmacology after her bachelor's (MBBS). For her, health communication is not just writing complicated reviews for professionals but making medical knowledge understandable and available to the general public as well.

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