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No Quirk Left Behind

Brett Hartman, Psy.D.

Coming in 2013, the American Psychiatric Association will unveil its newest version of the diagnostic manual: the DSM-5.  Although the guidebook may not top the New York Times bestseller list, it will instantly become the nation’s most influential book. 

Like earlier versions, the DSM-5 will serve as the standard for deciding who is and who is not mentally ill.  But all reports suggest that its scope will be broader, encompassing more areas of dysfunction, thus labeling more people.  Beyond the psychological effects of being labeled, the power of this single volume will be felt in a diverse range of institutions.  These include the legal system, education policy, economics, the media and the pharmaceutical industry.

Many have criticized earlier versions of the DSM as being little more than compilations of disorders by committee.  Aware of this complaint, the DSM-5 Task Force assures us that the new manual will be based on a foundation of scientific research, and that its members are free from conflicts of interest.  I would like to believe that both claims are true.  But even a cursory examination of some of the newly proposed disorders suggests otherwise.  I will briefly critique four proposed additions to the manual.

Hypersexual Disorder  How does one’s sexual appetite all of a sudden fall into the purview of mental disorder?  The most obvious explanation is that the media, not science, has opened the doorway.  Consider celebrities checking themselves into rehabs so that they can hide under the guise of addiction.  And consider the fact that SSRI anti-depressants are known to curb one’s sexual performance.  If by chance Hypersexual Disorder makes the final cut, psychiatrists can claim a new area of practice (and Tiger Woods can adopt a useful new label and a pill bottle to go along with his divorce papers).

Binge Eating Disorder  It is an appalling truth that far too many Americans are obese, and perhaps most of them got that way by eating too much—a lá binging.  I won’t add my take on the social and corporate influences on how this came to be.  But I will point out that this new label (as opposed to the standard: obesity) does very little to address our epidemic problem.  What it does, however, is shift the focus of treatment away from medicine and toward psychiatry.  No conflict of interest there.

Psychosis Risk Syndrome  This is truly the scariest proposal of all.  If approved, imagine a world in which psychiatrists and others in the field can identify patients—not merely on symptoms of psychosis—but on their risk for developing those symptoms.  This is a step backward into medieval psychiatry, when it was common to have people institutionalized for little more than distasteful behavior and the expectation of more to come.  Further, the notion of treating such people with heavy neuroleptics in the absence of symptoms has zero scientific credibility.  The only purposes I can imagine for this label are to increase psychiatry’s market share and thereby increase control over the masses.  Scary, indeed.

Temper Dysregulation Disorder with Dysphoria  Apparently none of the members of the Task Force has ever raised a child.  So allow me to offer a piece of education: children are not little adults.  They throw tantrums, they manipulate, and they get angry and sad in an effort to control the big world around them.  Why must we label them for doing what is essentially their nature?  The answer lies with the embarrassing statistics on Bipolar Disorder.  It has become a not-so-funny joke that when you send your misbehaving child into a psychiatric hospital, he or she will come out with a diagnosis of bipolar.  It’ll become a lot easier on the nerves (not to mention the reputation of psychiatrists) to diagnose TDD.  Meanwhile, insurance coverage and pharmacological approaches will remain unchanged.  TDD appears to be a sneaky way of treating as many children as possible with a less toxic label.

In conclusion, while there may be some intent among Task Force members to remain true to scientific data and free of bias, the DSM-5 will comprise a cross-section of competing interests.  These include increased market share for psychiatry, maximal coverage under existing health insurance protocols, continued dominance of pharmacological approaches, as well as, adherence to current social and political sensibilities.  Where does the individual fit into this scheme?  Ah yes, there does appear to be one unifying goal: to include as much breadth as possible so that no quirk is left behind.
Brett Hartman, Psy.D. is a psychologist and author of Hammerhead 84: a memoir of persistence.  He lives in Albany, NY with his wife and two (often misbehaving, but untreated) sons.

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