Psychiatrists rewriting the mental health bible
The Diagnostic and Statistical Manual of Mental Disorders, commonly called DSM, is getting an update. Now experts must decide what is a disorder and what falls in the range of normal human behavior.
Reporting from San Francisco -- Is the compulsion to hoard things a mental disorder? How about the practice of eating excessively at night?And what of Internet addiction: Should it be diagnosed and treated?
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The answers will determine how Americans' mental health is assessed, diagnosed and treated.
Over the next 18 months, psychiatrists will hammer out a draft of the fifth edition of the American Psychiatric Assn.'s Diagnostic and Statistical Manual of Mental Disorders, more commonly called DSM-V. Nowhere have the discussions been more heated, the ramifications most vividly foretold, than here at the organization's annual meeting.
Some psychiatrists warn that the tome runs the risk of medicalizing the normal range of human behaviors; others vehemently argue that it must be broad enough to guide treatment of those who need it.
But all agree that the so-called bible of psychiatry is expected to be considerably more nuanced and science-based than the last edition, DSM-IV, published in 1994.
Brain imaging and other technologies, plus new knowledge on biological and genetic causes of many disorders, have almost guaranteed significant alterations in how many mental afflictions are described.
"There are no constraints on the degree of change," said Dr. David J. Kupfer, chairman of the DSM-V task force and a psychiatrist at the University of Pittsburgh's Western Psychiatric Institute and Clinic.
The book will describe disorders in more detail, acknowledge variations that haven't been viewed as part of "classic" illness and explain how conditions differ based on age, race, gender, culture and physical health, Kupfer said.
Planning on the text began almost a decade ago, and leaders delivered a progress report to their colleagues last week. They emphasized that the book, slated for publication in 2012, should better reflect the lives and complexities of real people, not simply the most severe cases or most cut-and-dried diagnoses.
Critics of the current edition -- and there are many -- say that it allows for diagnosis only after a dramatic threshold has been reached.
"We are really hoping we'll be able to improve things," Kupfer said. "And that will help us do a better job of taking care of our patients."
Used around the world and available in 13 languages, the book has evolved from its humble origins in 1952 as a dry collection of statistics on psychiatric hospitalization. It is now used by not just psychiatrists, but internists, family practitioners, psychologists, social workers, courts and education professionals to guide the diagnosis and therapy for a host of mental and behavioral conditions. More than 1 million copies of DSM-IV have been sold.
Having a DSM diagnosis can mean an autistic child will get services from the public school system or that an adult is covered by workplace anti-discrimination laws.
For health insurance companies, it has become a basis for decisions on paying for care.
Some have questioned whether those writing the new book may be influenced by the pharmaceutical industry. Over the last two decades more medications have become available to treat mental disorders, and some doctors worry that the text may be written in a way that expands the market for drug therapies.
A study published online in the current issue of the journal Psychotherapy and Psychosomatics found that of 20 work group members writing clinical practice guidelines for the treatment of bipolar disorder, schizophrenia and major depression, 18 had at least one financial tie to industry.
A commentary in the May 7 New England Journal of Medicine said that 56% of DSM-V task force and committee members have industry ties.
DSM-V committee members have been asked to abide by conflict-of-interest rules, including agreeing to receive no more than $10,000 annually from industry sources during the period they serve on the committee.
But that isn't going far enough, said Lisa Cosgrove, lead author of the Psychotherapy and Psychosomatics analysis and an associate professor and clinical psychologist at the University of Massachusetts. "There are currently work groups where every single person has ties," Cosgrove said. "It doesn't seem like genuine progress has been made."
Regardless of the potential pitfalls of the upcoming edition, mental health professionals say, the current DSM doesn't always describe the people they are seeing, those with more than one disorder, a less-severe version of a disorder or one clearly diagnosable disorder but hints of other problems.
"In reality, there are a lot of shades of gray," said Dr. William E. Narrow, research director of the DSM-V task force.
The new version will help doctors craft more complex assessments. A person may meet the criteria of having depression, for example, but may also exhibit elements of anxiety or impulsiveness.
Also, mood disorders range widely from mild to severe, said Dr. Jan Fawcett, chairman of the mood disorders work group, one of 13 committees on the task force. A person with four of the nine listed symptoms for depressive disorder can be more troubled and disabled than another person with six of the nine symptoms.
"We don't want to take everyone who is demoralized by life and call it depression," he said. "But we also don't want to miss something."
Attention to finer shades will also help doctors and therapists recognize disorders in their earliest stages, when they are mild and easier to treat or prevent. Psychiatrists are especially interested in identifying prodromal forms, or earliest symptoms, of conditions such as bipolar disorder, schizophrenia and dementia, said Dr. William Carpenter Jr., psychiatry professor at the University of Maryland and chairman of the psychotic disorders work group.
Other changes simply reflect modern times, with obesity, for example, potentially to be labeled as a symptom of, or risk factor for, a mental disorder. This, among other things, may help doctors address a growing controversy on whether candidates for bariatric surgery are being adequately screened for their psychological health before they undergo the procedure.
"We know obesity is a risk factor for physical disorders and is probably a risk factor for psychiatric disorders too," Kupfer said. "The work group has spent time on what to do with obesity in DSM-V."
Gambling, sex addiction and Internet addiction -- formerly dismissed as harmful habits that could be defeated with willpower -- may also be labeled illnesses.
"It isn't a question of whether these things are real," Kupfer said. "They are. The question is whether there is enough empirical evidence to meet the threshold."
Leaders of the APA acknowledge the controversial nature of some of their discussions and have posted recent progress reports on the association's website, www.dsm5.org.
The meeting may have ended Thursday, but debates, revisions and studies are slated to last for 18 more months. And the new edition won't land on psychiatrists' desks with a note saying, "See you in 15 years." Task force members say it will be updated frequently.
shari.roan@latimes.com
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Bitterness as mental illness?
Bitter behavior is so common and deeply destructive that some psychiatrists are urging it be identified as a mental illness under the name post-traumatic embitterment disorder.
You know them. I know them. And, increasingly, psychiatrists know them. People who feel they have been wronged by someone and are so bitter they can barely function other than to ruminate about their circumstances.
This behavior is so common -- and so deeply destructive -- that some psychiatrists are urging it be identified as a mental illness under the name post-traumatic embitterment disorder. The behavior was discussed before an enthusiastic audience last week at a meeting of the American Psychiatric Assn. in San Francisco.
This behavior is so common -- and so deeply destructive -- that some psychiatrists are urging it be identified as a mental illness under the name post-traumatic embitterment disorder. The behavior was discussed before an enthusiastic audience last week at a meeting of the American Psychiatric Assn. in San Francisco.
The disorder is modeled after post-traumatic stress disorder because it too is a response to a trauma that endures. People with PTSD are left fearful and anxious. Embittered people are left seething for revenge.
"They feel the world has treated them unfairly. It's one step more complex than anger. They're angry plus helpless," says Dr. Michael Linden, a German psychiatrist who named the behavior.
Embittered people are typically good people who have worked hard at something important, such as a job, relationship or activity, Linden says. When something unexpectedly awful happens -- they don't get the promotion, their spouse files for divorce or they fail to make the Olympic team -- a profound sense of injustice overtakes them. Instead of dealing with the loss with the help of family and friends, they cannot let go of the feeling of being victimized. Almost immediately after the traumatic event, they become angry, pessimistic, aggressive, hopeless haters.
"They feel the world has treated them unfairly. It's one step more complex than anger. They're angry plus helpless," says Dr. Michael Linden, a German psychiatrist who named the behavior.
Embittered people are typically good people who have worked hard at something important, such as a job, relationship or activity, Linden says. When something unexpectedly awful happens -- they don't get the promotion, their spouse files for divorce or they fail to make the Olympic team -- a profound sense of injustice overtakes them. Instead of dealing with the loss with the help of family and friends, they cannot let go of the feeling of being victimized. Almost immediately after the traumatic event, they become angry, pessimistic, aggressive, hopeless haters.
"Embitterment is a violation of basic beliefs," Linden says. "It causes a very severe emotional reaction. . . . We are always coping with negative life events. It's the reaction that varies."
There are only a handful of studies on the condition, but psychiatrists at the meeting agreed that much more research is needed on identifying and helping these people. One estimate is that 1% to 2% of the population is embittered, says Linden, who has published several studies on the condition.
"These people usually don't come to treatment because 'the world has to change, not me,' " Linden says. "They are almost treatment resistant. . . . Revenge is not a treatment."
Nevertheless, Linden suggests that people once known as loving, normal individuals who suddenly snap and kill their family and themselves may have post-traumatic embitterment syndrome. That's reason enough for researchers to study how to treat the destructive emotion of bitterness.
**********************************************************************************
Campus isn't the most stressful thing
Whether in college or not, young adults have a lot of mental health issues to sort out.
Judy Foreman, Health Sense
March 2, 2009
A troubled, gun-wielding 23-year-old student at Virginia Tech goes on a campus rampage, killing 32 people and eventually himself. An MIT student commits suicide by ingesting cyanide, and another dies in a fire after a drug overdose.
Such highly publicized incidents underscore the sense of personal angst on today's college campuses. But contrary to popular belief, the stress on today's young people has nothing to do with meeting the demands of higher education.
It comes simply with being a newly minted adult.
Whether in college or not, almost half of this country's 19- to 25-year-olds meet standard criteria for at least one psychiatric disorder, although some of the disorders, such as phobias, are relatively mild, according to a government-funded survey of more than 5,000 young adults, published in December in the Archives of General Psychiatry. The study, done at Columbia University and called the National Epidemiologic Survey on Alcohol and Related Conditions, found more alcohol use disorders among college students, while their noncollegiate peers were more likely to have a drug use disorder. But, beyond that, misery is largely an equal-opportunity affliction.
Across the social spectrum, young people in America are depressed. They're anxious. They regularly break each other's hearts. And, all too often, they don't get the help they need as they face life's questions: "Who will I be? Will I make friends? The romantic relationships, planning for the future . . . there is all kinds of stuff going on at the same time, including raging hormones," says Ronald Kessler, a medical sociologist at Harvard Medical School.
Some evidence suggests that college students may even be less miserable than non-students their same age. Suicide -- the third leading cause of death for teenagers and young adults, according to the federal Centers for Disease Control and Prevention -- is one-third lower among the college than noncollegiate set, says Dr. Paul Barreira, a psychiatrist who is director of Behavioral Health and Academic Counseling at Harvard University Health Services.
The reason is not entirely clear, but studies have shown that, generally, higher education is often linked with better mental health. Mood disorders such as depression and anxiety affect slightly fewer college students than noncollegiate peers, researchers say.
And the biggest cause of despair? Even among college students, it's not academics, but love that hurts most. Emotional problems were more than twice as common among students who had recently had a major loss -- typically a romantic breakup -- than among those who had not, says Dr. Mark Olfson, the Columbia University psychiatrist who led the research for the National Epidemiologic Survey on Alcohol and Related Conditions.
The universality of youthful angst may come as a surprise in light of tragic college incidents. But to the experts, it makes perfect sense.
For one thing, early adulthood is the time when serious psychiatric problems such as bipolar disorder and schizophrenia often surface. For another, unhappiness in general follows a U-shaped curve, with the greatest unhappiness among young and very old adults, according to Kessler, the Harvard medical sociologist.
For the young, the trick is navigating a steep developmental curve -- figuring out who you are; getting work, family and finances on track; and generally stumbling toward independence.
An open question is whether life has always been this way for the young, or whether psychological problems are on the rise.
A 2006 survey of directors of college counseling centers suggests things are getting worse. But Dr. Andrew Leuchter, a psychiatrist and associate dean of the David Geffen School of Medicine at UCLA, says, "We don't know to what extent kids are having more difficulties and to what extent we are much better at recognizing and diagnosing them."
Barreira of Harvard agrees. "Most college counseling people would say students are more depressed today. But my hypothesis is that we're looking for it more and better at diagnosing it in high school. More students are showing up in college on medications -- they've been successfully treated so that they can get into good colleges."
For its part, Harvard is conducting a multi-year survey of mental health among incoming freshmen. And UCLA, despite general financial austerity, has launched a new initiative to help students with psychological problems.
That said, the Columbia study suggests that mental-health treatment is actually better outside the ivy-covered walls. While only 1 in 20 college students with psychological problems gets treatment, 1 in 10 of same-age non-students gets help. It's not clear why, says Olfson, the Columbia University psychiatrist.
"College students may be more concerned" that if they seek help they might jeopardize career opportunities or academic achievement, Olfson says, though he adds that, even so, "colleges should make more of an effort to make services available and acceptable, particularly for alcohol use problems."
Worried parents can help, too, whether their offspring are in school or in the job market. They can reassure their sons and daughters that it's not necessary to get all A's or move like lightning up the job ladder.
And perhaps most important, that broken hearts usually do heal.
health@latimes.com
There are only a handful of studies on the condition, but psychiatrists at the meeting agreed that much more research is needed on identifying and helping these people. One estimate is that 1% to 2% of the population is embittered, says Linden, who has published several studies on the condition.
"These people usually don't come to treatment because 'the world has to change, not me,' " Linden says. "They are almost treatment resistant. . . . Revenge is not a treatment."
Nevertheless, Linden suggests that people once known as loving, normal individuals who suddenly snap and kill their family and themselves may have post-traumatic embitterment syndrome. That's reason enough for researchers to study how to treat the destructive emotion of bitterness.
**********************************************************************************
Campus isn't the most stressful thing
Whether in college or not, young adults have a lot of mental health issues to sort out.
Judy Foreman, Health Sense
March 2, 2009
A troubled, gun-wielding 23-year-old student at Virginia Tech goes on a campus rampage, killing 32 people and eventually himself. An MIT student commits suicide by ingesting cyanide, and another dies in a fire after a drug overdose.
Such highly publicized incidents underscore the sense of personal angst on today's college campuses. But contrary to popular belief, the stress on today's young people has nothing to do with meeting the demands of higher education.
It comes simply with being a newly minted adult.
Whether in college or not, almost half of this country's 19- to 25-year-olds meet standard criteria for at least one psychiatric disorder, although some of the disorders, such as phobias, are relatively mild, according to a government-funded survey of more than 5,000 young adults, published in December in the Archives of General Psychiatry. The study, done at Columbia University and called the National Epidemiologic Survey on Alcohol and Related Conditions, found more alcohol use disorders among college students, while their noncollegiate peers were more likely to have a drug use disorder. But, beyond that, misery is largely an equal-opportunity affliction.
Across the social spectrum, young people in America are depressed. They're anxious. They regularly break each other's hearts. And, all too often, they don't get the help they need as they face life's questions: "Who will I be? Will I make friends? The romantic relationships, planning for the future . . . there is all kinds of stuff going on at the same time, including raging hormones," says Ronald Kessler, a medical sociologist at Harvard Medical School.
Some evidence suggests that college students may even be less miserable than non-students their same age. Suicide -- the third leading cause of death for teenagers and young adults, according to the federal Centers for Disease Control and Prevention -- is one-third lower among the college than noncollegiate set, says Dr. Paul Barreira, a psychiatrist who is director of Behavioral Health and Academic Counseling at Harvard University Health Services.
The reason is not entirely clear, but studies have shown that, generally, higher education is often linked with better mental health. Mood disorders such as depression and anxiety affect slightly fewer college students than noncollegiate peers, researchers say.
And the biggest cause of despair? Even among college students, it's not academics, but love that hurts most. Emotional problems were more than twice as common among students who had recently had a major loss -- typically a romantic breakup -- than among those who had not, says Dr. Mark Olfson, the Columbia University psychiatrist who led the research for the National Epidemiologic Survey on Alcohol and Related Conditions.
The universality of youthful angst may come as a surprise in light of tragic college incidents. But to the experts, it makes perfect sense.
For one thing, early adulthood is the time when serious psychiatric problems such as bipolar disorder and schizophrenia often surface. For another, unhappiness in general follows a U-shaped curve, with the greatest unhappiness among young and very old adults, according to Kessler, the Harvard medical sociologist.
For the young, the trick is navigating a steep developmental curve -- figuring out who you are; getting work, family and finances on track; and generally stumbling toward independence.
An open question is whether life has always been this way for the young, or whether psychological problems are on the rise.
A 2006 survey of directors of college counseling centers suggests things are getting worse. But Dr. Andrew Leuchter, a psychiatrist and associate dean of the David Geffen School of Medicine at UCLA, says, "We don't know to what extent kids are having more difficulties and to what extent we are much better at recognizing and diagnosing them."
Barreira of Harvard agrees. "Most college counseling people would say students are more depressed today. But my hypothesis is that we're looking for it more and better at diagnosing it in high school. More students are showing up in college on medications -- they've been successfully treated so that they can get into good colleges."
For its part, Harvard is conducting a multi-year survey of mental health among incoming freshmen. And UCLA, despite general financial austerity, has launched a new initiative to help students with psychological problems.
That said, the Columbia study suggests that mental-health treatment is actually better outside the ivy-covered walls. While only 1 in 20 college students with psychological problems gets treatment, 1 in 10 of same-age non-students gets help. It's not clear why, says Olfson, the Columbia University psychiatrist.
"College students may be more concerned" that if they seek help they might jeopardize career opportunities or academic achievement, Olfson says, though he adds that, even so, "colleges should make more of an effort to make services available and acceptable, particularly for alcohol use problems."
Worried parents can help, too, whether their offspring are in school or in the job market. They can reassure their sons and daughters that it's not necessary to get all A's or move like lightning up the job ladder.
And perhaps most important, that broken hearts usually do heal.
health@latimes.com
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