Fixing temper tantrums
One of the most hotly debated additions to the manual is “Disruptive Mood Dysregulation Disorder,” which critics worry will see more kids receive a diagnosis – and possibly medication – for what may really be just awful temper tantrums. The actual criteria is somewhat more stringent: The diagnosis is meant to cover children and teens who have lengthy and sever “temper outbursts” three or more times a week.
DMDD, as it will be called, has “probationary” status, recognizing that there isn’t a lot of research to support the disorder (its inclusion will help researchers investigate it). It was included because of concerns that troubled children were being mislabelled with bipolar disorder – a highly questionable diagnosis in children that has seen a steep rise in the last decade. In addition to being saddled with a lifelong condition, this often led to the prescription of antipsychotic and mood-stabilizing drugs, which haven’t been tested on kids. The DMDD diagnosis is meant to give physicians a new label for these complicated patients, one without the baggage and stigma of the adult disorder. Moss rejects the notion that the diagnosis will become a catch-all for kids with normal tantrums. “A child like that would soon be screened out, and mom and dad are going to be sent to parenting class.”
But Frances says that there is no guarantee that the new diagnosis itself wouldn’t be treated with medication, especially when child psychologists are in short supply – and when many patients are first seen by family doctors, with little training in the field. “These aren’t academic questions,” says Frances. “It’s not something you throw out there and see how it works. These are people’s lives.”
Breaking out binge eating
Much of the in-fighting around the DSM involved determining the criteria for a diagnosis. The manual has always given psychiatrists some wiggle room when they see patients whose symptoms are severe but not packaged neatly into a clear diagnosis. In the eating-disorder category, binge eaters are often placed in that more open-ended “not-otherwise-specified” category.
But that doesn’t help researchers and it may complicate treatment. Dr. Giorgia Tasca, director of Ottawa’s Centre for Eating Disorders Research, estimates binge-eating makes up at least 20 per cent of his non-specified cases – a statistic believed to be much higher in community-based programs. The disorder, in which people eat to excess but don’t purge afterward, “is very different from Thanksgiving dinner, where you are eating way too much, but it’s a social, pleasurable event,” says Tasca. “People typically do it in secret. And they will say, ‘I couldn’t stop myself. I couldn’t help it.’”
The DSM has controversially lowered the criteria – instead of two times a week for six months, patients can be diagnosed if they binge eat once a week for three months. (The treatment is typically psychotherapy, but anti-depressants may be prescribed.) Tasca expressed concerns about lowering the bar for the disorder. “I don’t know if there is enough research to support it.” But the impact of the change – particularly, how many people will be diagnosed – won’t be known for many years.
Refining adult ADHD
The DSM, like the Bible, is open to interpretation, which is what makes its wording so important. “If a diagnosis doesn’t make sense,” says Moss, “physicians will vote with their feet. They won’t use it.” But that’s overly optimistic, critics argue, pointing to the decision to give Adult Attention Deficit Hyperactivity Disorder (ADHD) it’s own stand-alone diagnosis.
Dr. Lily Hechtman, professor of psychiatry and pediatrics at McGill University and an expert in ADHD, says the previous description was based on field trials with children. The new manual has added criteria such as quitting jobs repeatedly, ending long-term relationships abruptly, running red lights. Of the 5 to 10 per cent of children diagnosed with ADHD, Hechtman says, it’s now estimated at least half of them have trouble managing the symptoms in adulthood. In her view, the revised DSM more accurately reflects the knowledge of the last decades, and if followed strictly, the diagnosis shouldn’t expand prevalence of the disorder among adults.
But critics are concerned that it will become too easy for adults to get medication for everyday distraction and stress. Frances points out that in all three revisions he oversaw in the 2000 edition of the DSM-IV (one of which included pulling Asperger’s out from under the autism umbrella) the rates of diagnosis increased many times more than they had predicted, and that is especially true when there’s a drug available. “However well-intended the suggestion, it’s the translation to actual clinical practice that is treacherous,” Frances says. “What’s written in the manual doesn’t determine how it will be used, particularly with drug companies on the sidelines with huge marketing budgets.”