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.

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."

High on their list of concerns is the absence of transparency. Last July, Spitzer warned readers of Psychiatric News that the amount of secrecy cloaking the revisions was unprecedented and alarming. He quoted the contract that participants are required to sign, which reads, in part:

I will not, during the term of this appointment or after, divulge, furnish, or make accessible to anyone or use in any way ... any Confidential Information. I understand that "Confidential Information" includes all Work Product, unpublished manuscripts and drafts and other pre-publication materials, group discussions, internal correspondence, information about the development process and any other written or unwritten information, in any form, that emanates from or relates to my work with the APA task force or work group.

The APA alleges that the paragraph was not meant to block input from interested colleagues or output to the media (for which we are still waiting, by the way!). The president of the APA and the vice chair of the DSM-V task force bluntly dismissed other complaints about secrecy, insisting, against all contrary evidence, that its procedure is "a model of transparency and inclusion." The agreement was allegedly crafted to protect intellectual property. (The DSM is already copyrighted.) But the agreement also remains binding even afterDSM-V is published; to avoid breaking it, participants must keep their drafts, memos, and working papers to themselves. Apparently we're never to know exactly how or why bitterness, anger, and Internet addiction become mental disorders. Indeed, the contract appears to have been designed to make that omission a foregone conclusion—otherwise, why did the APA enforce it so rigidly at the start? When Spitzer requested the minutes of earlier discussions, he was told that if the APA made them available to him, it would need to share them with others.

After Frances made his objections public last month, he and Spitzer followed up by sending the APA an open letter: "Unless you quickly improve the internal APA DSM-V review process, there will inevitably be increasing criticism from the outside. Such public controversy will raise questions regarding the legitimacy of the APA's continued role in producing subsequent DSMs—a result we would all like to avoid."

Spitzer and Frances also strongly disagree with a proposal to include "subthreshold" and "premorbid" diagnoses in the new manual. Both terms give cover to the so-called "kindling" theory of mental illness in children and infants—some psychiatrists believe that it's possible to stamp out ailments before they burgeon into full-blown disorders. *

The kindling theory of infant mental disorders reminds us—as Darrel Regier (then the APA's deputy medical director) told the FDA's Psychopharmacologic Drugs Advisory Committee in October 2005—that the APA already considers 48 million Americans mentally ill. "Subthreshold" and "premorbid" diagnoses, warn Spitzer and Frances, "could add tens of millions of newly diagnosed 'patients' "—their quotation marks—to that roster, "the majority of whom would likely be false positives subjected to the needless side effects and expense of treatment." Conceivably, we might by 2012 reach a point where the APA is defining more than half the country as mentally ill.

"In its effort to increase diagnostic sensitivity," Spitzer and Frances conclude, the DSM-V task force "has been insensitive to the great risks of false positives, of medicalizing normality, and of trivializing the whole concept of psychiatric diagnosis." These are remarkable accusations from two men who, between them, oversaw the formal approval of more than 150 mental disorders in two-dozen years.

In three years' time, will bitterness be seen as one of these disorders? Count me among the afflicted, if you must; some days that does seem possible, even likely. Given its track record and the grave doubts of two former editors of the DSM, should the APA really be given sole rights to decide something so consequential?

Correction, Aug. 3, 2009: This paragraph originally included two sentences about an article from the St. Petersburg Times on prescribing psychiatric drugs to very young children. The St. Petersburg Times article was about the sharp decline in such prescriptions in Florida in 2008, following new regulations, but the Slate piece reported only the much higher rates of prescriptions in 2007, misrepresenting the contents of the St. Petersburg Times' reporting. Those two sentences have been deleted. (Return  to the corrected paragraph.)

Christopher Lane is the author, most recently, of Shyness: How Normal Behavior Became a Sickness.