US DSM-5 for diagnosing mental disorders published - Asperger's is Out!

In the manual, grief is newly medicalised as major depressive disorder (MDD). 

Credit: Adam G. Gregor /Alamy

The field of mental health will face its greatest upset in years on Saturday with the publication of the long-awaited and deeply-controversial US manual for diagnosing mental disorders.

Early drafts of the book, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, have divided medical opinion so firmly that authors of previous editions are among the most prominent critics.

Known informally as the psychiatrists' bible, the $199 tome from the American Psychiatric Association is the guidebook that US doctors will use to diagnose mental disorders. The latest edition is the first major update in 20 years.

Though not used in the UK, where doctors turn to the World Health Organisation's International Statistical Classification of Diseases (ICD), the US manual has global influence. It defines groups of patients, and introduces new names for disorders.

Those names can spread, and become the norm elsewhere, but more importantly, the categories redefine the populations that are targeted by drugs companies.

Criticisms have come from almost every corner. There are claims of expansionism, with common experiences and behaviours becoming newly medicalised.

Allen Frances

Temper tantrums become Disruptive Mood Dysregulation Disorder (DMDD); grief becomes major Depressive Disorder (MDD), according to Allen Frances, an American psychiatrist who chaired the task force behind the fourth edition of the manual.

Other behaviours get their own labels: overeating becomes binge eating disorder; keeping too much junk, a hoarding disorder; a bit forgetful could be mild neurocognitive disorder.

David Clark

David Clark, professor of experimental psychology at Oxford University, said "Mental health disorders are often hard to divide into clear categories, because too little is known about them, and there can be major overlaps. But the definitions are often valuable. For example, greater distinctions between various types of anxiety have led to more specific and effective treatments."

Nick Craddock, professor of psychiatry at Cardiff University, and director of the National Centre for Mental Health in Wales, said "Some of the stranger aspects of the US manual will have no impact in Britain. DSM-5 was flawed because definitions of disorders were sometimes changed on the basis of too little fresh scientific evidence."

"I don't believe the science has advanced sufficiently in 20 years since DSM-4 to warrant making a new system," he said. "That essentially is just a group of people agreeing on tweaking things and making them appear a little bit different. That to me is not a very helpful stage in the develop of psychiatric diagnosis. This is the wrong time in history to change the diagnostic system."

Changing the definitions of disorders alters who has them. That affects who gets drugs and other support, and who interventions are trialled on. If the criteria for attention Deficit Hyperactivity Disorder (ADHD) are broadened, then more people are likely to be diagnosed with the condition.

The arrival of DSM-5 will mean the end of Asperger's syndrome in the professional eyes of the US psychiatric arena.

Along with some other autism-related conditions, Asperger's will now be consumed by the new category of "autism spectrum disorder".

Carol Povey

Some people diagnosed with Asperger's are unhappy about the coming change. Carol Povey, director of the National Autistic Society's Centre for Autism, said: "The term Asperger Syndrome is a core part of their identity for many people and they understandably feel anxious about moves to remove the term. The changes won't prevent people from continuing to use it to define themselves and nor should it," she said.

Debbie Tucker, chair of the Asperger's Syndrome Foundation, said the label can be useful in treating people, but that some did not want to be labelled. "Labels only become unhelpful and sometimes dangerous if used to discriminate. People with Aspergers are vulnerable to this," she said.

Thomas Inse

Last month, Thomas Insel, director of the National Institute of Mental Health, declared that the organisation would not use DSM-5 definitions to set its research priorities. Writing about DSM-5 on his blog, he said: "The weakness is its lack of validity. Unlike our definitions of ischaemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure."

Instead, he said the NIHM would lay the foundations for a new classification system, based on brain imaging, genetics, cognitive science and other research.

"We need to begin collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response," he said.

Children’s School Absenteeism Linked to Mental disorder

Being absent and missing out on class can be hard on children as they get to miss out on valuable lectures.

This can often times lead to poorer performances, and worse, can lead to ridicule from peers but the reason behind children's absenteeism may be far more problematic than missing out on class as new research finds it may be linked to their mental health.

Students who are frequently absent from school are more likely to have symptoms of psychiatric disorders, according to Jeffery Wood, associaten professor of educational psychology and psychiatry at University of California, Los Angeles, who led the study.

In the study, researchers looked at more than 17,000 children in 1st through 12th grades and found that between grades 2 and 8, students who already had mental health symptoms missed more school days over the course of a year than they had in the previous year and than students with few or no mental health symptoms.

These frequent absents, researchers said, is linked with a higher prevalence of mental health problems later on when they reach adolescence.

Findings al show that middle and high school students who were chronically absent in an earlier year of the study tended to have more depression and antisocial problems in subsequent years, leading to missing additional school days in the following years.

Wood noted that their findings may aid others in helping students address mental health issues that in turn, prevent the emergence of chronic absenteeism.

And indeed, mental illness among children must be addressed soon. This is because the problem has become so common that about 20% of American children suffer from a diagnosable mental illness, and that around 5 million American children and adolescents suffer from a serious mental illness, according to MedicineNet.com.

The most common among the mental illnesses in children are anxiety disorders, disruptive behavior disorders, eating disorders, learning and communication disorders, and even schizophrenia.

But in order to successfully deal with a mental illness, a person must be able to identify when a child is suffering from them. Though symptoms may vary from one mental illness to another, some symptoms that generally appear when a child has a mental disorder are:

- Inability to cope with daily problems and activities

- Changes in sleeping and eating habits

- Defying authority, skipping school, stealing, or damaging property

- Frequent outbursts of anger

- Long-lasting negative moods

- Changes in school performance, such as getting poor grades

- Loss of interest in friends and activities they usually enjoy

ADHD: Training and Support for Clinicians

Aims
The ADHD website aims to give information to clinicians including general practitioners, GPWsi's, community paediatricians and CAMHS staff on:
.
a) ADHD and related neurodevelopmental disorders;
b) Identifying the signs and symptoms of ADHD including consideration of the differential diagnoses, co-morbid disorders and associated functional difficulties;
c) Management options for children with ADHD and their families including behavioural strategies and prescribing options;
d) How to manage ongoing care and support for children with ADHD and their families including medication monitoring.
.
The information provided on the website could be used as :

1. an introductory training package for GP's with a special interest (GPWsi's) in children's mental health, in particular in ADHD, who wish to take a lead on this topic within their practice area;
2. an introductory training package for non consultant clinical staff who work in ADHD clinics run by either by Child and Adolescent Mental Health Services (CAMHS) or paediatric departments e.g. GP clinical assistants, senior nurse practitioners and junior/ middle grade medical staff. It is advised that this information is complemented by on site clinical supervision from a consultant with special expertise in ADHD.
3. training materials about ADHD for all GP's who have children and young people on their lists with this disorder and to act as a pointer to websites which may be useful to clinicians and parents. The site may be of particular interest to GP's providing ADHD monitoring enhanced services.
4. an aid for a seamless transfer of specific aspects of patient treatment from the secondary sector to general practice. Information is provided on the nature of the condition treated, the medications in question, the monitoring required and the responsibilities of the parties involved.

This website can also be utilised as a part of a PG Cert Course (30 credits at Masters Level, ‘subject to validation’) with the University of Wales, Newport. Please contact amanda.kirby@newport.ac.uk for further information.
.
The course aims are as follows:
The module will provide student knowledge in the following areas

• An understanding of the signs and symptoms of ADHD in children, adolescents and adults
• An understanding of the assessment and diagnosis of ADHD in children and adolescents
• The principles of a multi-modal treatment package for ADHD.
• The knowledge of non pharmacological interventions for ADHD
• An understanding of the pharmacological interventions for ADHD
• The understanding of issues of medication including
• Starting medication
• Switching medication and polypharmacy
• Medication monitoring
• The issues of the management of the ADHD- follow up clinics
• Consideration of ADHD in relationship to other co-morbid disorders

The Learning Outcomes are as follows:

On completion of the PG Cert module the student would:

1. Have an understanding of current knowledge and theory relating to the aetiology underpinning ADHD and related co-morbid disorders.
2. Be able to critically reflect upon the management and intervention options for supporting an individual with ADHD.
3. Demonstrate knowledge of current practices in the management of the individual with ADHD in the context of common health and educational practices and through a consideration of research undertaken in this area.
4. Demonstrate an understanding of the choices for treatment both pharmacological and non pharmacological.
5. Critically reflect upon the different factors that may impact on the individual’s difficulties at home and at school and in further education.
6. The student will gain knowledge of the management principles of running a follow up ADHD clinic.

These aims are informed by the following philosophy:

Improving access to knowledge on ADHD for the groups of clinicians above will help to combine the best of primary and secondary care for the benefit of these patients and their families.

Shared care arrangements between primary and secondary care are thought to be essential for safe, effective and efficient treatment with complex drugs such as those used in the medical treatment of ADHD.

Entry into a shared care arrangement is voluntary for all parties involved. It should be noted that clinical responsibility lies with the prescribing doctor.

GPs and other clinicians should therefore familiarise themselves with the drug treatments they are prescribing, ensure an acceptable monitoring arrangement is in place and feel confident that they can obtain appropriate specialist support when required.

Glossary of Abbreviations

• ADHD = Attention Deficit HyperactivityDisorder
• ASD = Autistic Spectrum Disorder
• CBT = Cognitive Behaviour Therapy
• CD = Conduct Disorder
• DCD = Developmental Co-ordination Disorder
• DSM-1V= Diagnostic and Statistical Manual of Mental Disorders (4th Edition)
• HKD = Hyperkinetic Disorder
• ICD-10 = International Classification of Diseases (10th version)
• IEP = Individual Education Plan
• LSA = Learning Support Assistant
• LEA = Local Education Authority
• ODD = Oppositional Defiant Disorder
• SDQ = Strengths and Difficulties Questionnaire
• SEN = Special Educational Need
• SENCO= Special Educational Needs Co-ordinator
• TCA = Tricylic antidepressant
• WISC = Wechsler Intelligence Scale for Children 

Bipolar kids: Victims of the 'madness industry'?

THERE'S a children's picture book in the US called Brandon and the Bipolar Bear. Brandon and his bear sometimes fly into unprovoked rages.

Sometimes they're silly and overexcited. A nice doctor tells them they are ill, and gives them medicine that makes them feel much better.

The thing is, if Brandon were a real child, he would have just been misdiagnosed with bipolar disorder.

Also known as manic depression, this serious condition, involving dramatic mood swings, is increasingly being recorded in American children. And a vast number of them are being medicated for it.

The problem is, this apparent epidemic isn't real. "Bipolar emerges from late adolescence," says Ian Goodyer, a professor in the department of psychiatry at the University of Cambridge who studies child and adolescent depression. "It is very, very unlikely indeed that you'll find it in children under 7 years."

How did this strange, sweeping misdiagnosis come to pass? How did it all start? These were some of the questions I explored when researching The Psychopath Test, my new book about the odder corners of the "madness industry".

Freudian slip

The answer to the second question turned out to be strikingly simple. It was really all because of one man: Robert Spitzer.

I met Spitzer in his large, airy house in Princeton, New Jersey. In his eighties now, he remembered his childhood camping trips to upstate New York. "I'd sit in the tent, looking out, writing notes about the lady campers," he said. "Their attributes." He smiled. "I've always liked to classify people."

The trips were respite from Spitzer's "very unhappy mother". In the 1940s, the only help on offer was psychoanalysis, the Freudian-based approach of exploring the patient's unconscious. "She went from one psychoanalyst to another," said Spitzer. He watched the psychoanalysts flailing uselessly. She never got better.

Spitzer grew up to be a psychiatrist at Columbia University, New York, his dislike of psychoanalysis remaining undimmed. And then, in 1973, an opportunity to change everything presented itself. There was a job going editing the next edition of a little-known spiral-bound booklet called DSM - the Diagnostic and Statistical Manual of Mental Disorders.

DSM is simply a list of all the officially recognised mental illnesses and their symptoms. Back then it was a tiny book that reflected the Freudian thinking predominant in the 1960s. It had very few pages, and very few readers.

What nobody knew when they offered Spitzer the job was that he had a plan: to try to remove human judgement from psychiatry. He would create a whole new DSM that would eradicate all that crass sleuthing around the unconscious; it hadn't helped his mother.

Instead it would be all about checklists. Any psychiatrist could pick up the manual, and if the patient's symptoms tallied with the checklist for a particular disorder, that would be the diagnosis.

Bipolar kids: Victims of the 'madness industry'? - health - 08 June 2011 - New Scientist

Resources for Schools | Stamp Out Stigma of Mental Health

Resources for Schools | Stamp Out Stigma of mental Health

New Diagnostic Guidelines for DSM: The Manual for Mental Disorders

New Diagnostic Guidelines for Mental Illnesses Proposed - BusinessWeek

For the first time in more than a decade, the American Psychiatric Association has announced proposed changes to the Diagnostic and Statistical Manual of Mental Disorders (DSM), long considered the "Bible" of psychiatry.

Unlike its predecessor, DSM-4, the new DSM-5 would not formally recognize sex and Internet addictions; would create a new category for "risk" disorders for people possibly heading towards developing full psychosis or dementia; and would create a new disorder, "temper dysregulation with dysphoria" (TDD) to incorporate both mood and behavioral disturbances, partly a response to current overdiagnosis of juvenile bipolar disorder.

Other issues were also addressed, including creating an overarching category known as "autism spectrum disorders" to encompass autism, Asperger's syndrome and other similar conditions. This term is already widely used. And "mental retardation" would become "intellectually challenged."

DSM is the tome used by psychiatrists and other mental health professionals to diagnose different conditions and to guide research.

The proposed draft will be available for public comment until April 20. The final document, which has already been 10 years in the making, is expected to be released in 2013. The DSM-4 was published in 1994.

One of the major changes in the proposed volume will be a move toward "dimensional assessments" for mental disorders, meaning that strict, immutable categories will be replaced by a reliance on continuums and that "cross-cutting" symptoms -- those that span several different disorders -- will be included in the criteria.

"There's no measure in the [DSM-4] to account for the severity of the disorder and therefore no way to measure if a patient, on quantitative measures, is improving with treatment," Dr. Darrel Regier, vice chair of the DSM-5 Task Force and director of research for the American Psychiatric Association, said during a Tuesday teleconference announcing the proposed changes. "We're trying to address this with more quantitative measures on a continuum with a cut-off to decide mild, severe, very severe."

This time around, experts say they are giving "careful consideration" to how mental health disorders might vary according to race, gender and ethnicity.