The diagnostic madness of DSM-V.

Health and medicine explained.
July 24 2009 9:31 AM

Bitterness, Compulsive Shopping, and Internet Addiction

The diagnostic madness of DSM-V.

DSM's fourth edition
DSM's fourth edition

There's an awful lot of money to be made from compulsive shopping, judging by the career of Madeleine Wickham. Her Shopaholic series, written under the pen name Sophie Kinsella, is required reading for chick-lit enthusiasts, and the romantic comedy Confessions of a Shopaholic, the first of several planned big-screen adaptations, grossed more than $100 million worldwide. While the film, starring Isla Fisher, isn't terribly funny, it does make the valid point that to enjoy shopping for elegant clothes isn't a pathology. It's a style.

The American Psychiatric Association risks losing sight of that distinction by grimly—and rather inexpertly—debating whether avid shopping should be considered a sign of mental illness. The fifth edition of the association's Diagnostic and Statistical Manual of Mental Disorders is expected in 2012. The APA isn't just deciding the fate of shopaholics; it's also debating whether overuse of the Internet, "excessive" sexual activity, apathy, and even prolonged bitterness should be viewed, quite seriously, as brain "disorders." If you spend hours online, have sex more frequently than aging psychiatrists, and moan incessantly that the federal government can't account for all its TARP funds, take heed: You may soon be classed among the 48 million Americans the APA already considers mentally ill.

Quite how the association will decide when normal kvetching becomes a sickness—or reasonable amounts of sex become excessive—is still anyone's guess. Behind the APA's doors in Arlington, Va., the fine points of the debate are creating quite a few headaches. And they're also causing a rather public dust-up.

To linger anxiously, even bitterly, over job loss is all too human. To sigh with despair over precipitous declines in one's retirement account is also perfectly understandable. But if the APA includes post-traumatic embitterment disorder in the next edition of its diagnostic bible, it will be because a small group of mental-health professionals believes the public shouldn't dwell on such matters for too long.

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That's a sobering thought—enough, perhaps, to make you doubt the wisdom of those updating the new manual. The association has no clear definition of the cutoff between normal and pathological responses to life's letdowns. To those of us following the debates as closely as the association will allow, it's apparent that the DSM revisions have become a train wreck. The problem is, everyone involved has signed a contract promising not to share publicly what's going on.

Back in 1952, when the APA's diagnostic manual first appeared, it was a thin, spiral-bound edition that offered sketches of such '50s-sounding traits as passive-aggressive personality disorder, emotionally unstable personality disorder, and inadequate personality disorder. It was seen more as a guide to psychiatry than as a chapter-and-verse authority on everything pertaining to mental health. Somehow it acquired those pretensions in 1980, with publication of the third edition, which included more than 100 new mental disorders, quite a few of them still being contested.

Inadequate personality wasn't quite dropped from DSM-III; it was allowed to merge with "atypical, mixed, or other personality disorder," which is, if anything, even more nebulous. Among the more hair-raising mental illnesses also added to the manual were avoidant personality disorder, oppositional defiant disorder, and social phobia. The latter's symptoms to this day include fear of eating alone in public and concern that "one will act in a way … that will be humiliating and embarrassing." The DSM also included such gems as caffeine intoxication disorder, mathematics disorder, sibling relational problem, and frotteurism, the "intentional rubbing up against or touching of another, usually unsuspecting, person for the purpose of sexual arousal."

The DSM now contains three times as many disorders as it did in 1952 and is more than seven times longer than that first edition. The jury is still out on whether the dozens of new additions hold up to scientific scrutiny. Robert Spitzer, editor of two previous editions, including the one that formally approved post-traumatic stress disorder, recently conceded that his colleagues must now "save PTSD from itself."

To its members and to the public, the APA boasts that the manual is rigorous and evidence-based, drawing meticulously on data and field trials. But the very fact that the APA has produced a task force to decide whether bitterness, apathy, extreme shopping, and overuse of the Internet belong in the manual indicates, as Allen Frances, who chaired the DSM-IV task force, told Psychiatric News last month, that DSM-V is "headed in a very wrong direction." "I don't think they realize the problems they are about to create," he declared, "nor are they flexible enough to change course."

Serious questions have also surfaced about the competence, procedure, and secrecy of the DSM-V task force. And the two most vocal skeptics are Frances and Spitzer, former editors of the manual.In one open letter, they chide the APA's leaders for creating a "rigid fortress mentality," insisting that "continuing problems … have forced us to intervene in so public a way."

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