Updates to psychiatric guide spur controversy

A panel of psychiatrists charged with updating the reference manual used to diagnose mental illness in the United States has abandoned controversial plans to add new diagnoses for people with mild psychosis and those who are simultaneously anxious and sad — even as the committee has left in place a host of other proposals that have ignited fierce criticism from professionals in the field.

The American Psychiatric Association revealed last week that it will scrap plans to add two new conditions to the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders, or DSM-5 — the massive tome considered the bible of modern psychiatry.

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The first condition, “attenuated psychosis risk,” was meant to identify young people in danger of developing a full-blown psychotic disorder as they get older. But many psychiatrists complained that scant evidence exists that the symptoms — for instance, occasional mild hallucinations or delusional thinking — reliably predict later psychosis. And they warned that a diagnosis could prompt doctors to needlessly treat many youngsters with powerful antipsychotic drugs that have harmful side effects.

More research needed

Also gone is a proposed category for “mixed anxiety depressive disorder” that critics charged could label the challenges of everyday life a mental condition. Both categories will instead be put in a section of the DSM-5 for conditions requiring further research.

The modifications were among a series unveiled Wednesday that will be open to a third and final round of public comment lasting six weeks, through June 15. The 162-member group charged with revising the DSM-5 could make further changes in the next several months since the final draft is not due to the printer until the end of the year, with publication scheduled for May of next year.

David Kupfer, a professor of psychiatry at the University of Pittsburgh School of Medicine and chairman of the current task force, said the latest tweaks showed the committee was responding to outside opinion and comment.

“We have not made decisions ahead of time,” he said. “I am spending 24-7 with 160 colleagues trying to do the best we can to listen to everybody.”

But the years-long drafting process has been dogged by delays and allegations of disorganization and secrecy. That process looms large over the psychiatric association as it opened its annual conference in Philadelphia on Saturday.

The stakes are heightened by the outsize role the DSM plays in American society. Used by medical professionals to assign patients diagnostic codes based on their symptoms, the DSM’s wording can affect what treatments a person is prescribed, whether their health insurance pays for it, what school and social services they are entitled to, and how long they can be committed by a court.

Allen J. Frances, chairman of the committee that updated the current, fourth edition of the DSM in the 1990s, and among the most prominent critics of the latest effort, also pointed to aggressive tactics adopted by pharmaceutical companies in recent years. Eager to identify new customers, he said, they were quick to capi­tal­ize on seemingly minor expansions made to categories in the current DSM by directly marketing to the public or to primary care doctors and OB-GYNs — who, while less trained in the nuances of mental illness, prescribe the largest share of many psychiatric medications, including antidepressants.