The Future of Mental Health...Official Mental Health that Gets an Insurance Code

Narcissism out.  Asperger's out.  Pervasive Developmental Disorder out. The Autistic Spectrum collapsed. 

The new Diagnostic and Statistical Manual, aka "the bible" of the mental health field, likely will include these revisions and more come 2013. The American Psychiatric Association hasn't overhauled it since 1994 when we still thought of autism as a rare disorder marked by extreme deficits and impairments.  Back then ADHD was king and autism was the guy in Rain Man

A recent article in the LA Times (paper has a great Health section) hits on some of the more fascinating quandaries facing the psychiatrists and psychologists trying to figure out what determines a so-called mental disorder, not so easy these days given advances in neurological imaging and molecular biology that blur the line between mental and physical health.

For instance, Alzheimer's is recognized as a medical condition and yet it features impaired cognitive function, a typical "mental" component and as such might qualify some individuals for one of the new mild cognitive conditions in the next DSM. 

But despite all the fancy new research that costs a fortune there still are no definitive biological or physiological markers of autism, ADHD, depression or any other mental disorder.  We can't take a picture of the brain and make a diagnosis.  We still (and hopefully always will) look to behavior for deciding what's problematic.

Bringing me to the next issue.  How bad off do people have to be to get a diagnosis?

Should someone be diagnosed even if they appear to be functioning okay at work, school, in marriages, friendships, etc?  We all know people like this, right?

But it gets even harder to define okay when it comes to kids who are notoriously irregular in their development and who have more help navigating the world.  Their social limitations may not be obvious as they have more limited social demands than adults. 

How about when we have, say, a young child with communication delays and mild other behavioral symptoms.  Should we go ahead and use Pervasive Developmental Disorder- Not Other Specified (on the autistic spectrum now but to be collapsed into autism in the new DSM)?  There's an argument that kids who could benefit from early intervention should be labeled and get the treatment.  It can be difficult to figure out to what degree a child is not "functioning" in part because kids develop at different rates.  It's not clear where the line should be drawn between diagnosis and (irregular) child development. 

Remember the study out last summer finding children who start kindergarten at an earlier age are more likely to be diagnosed with ADHD?  Hard to argue the diagnosis isn't in some part socially-constructed and thus has more to do with brain development than brain "dysfunction":  
The researchers figured that children born just a few days apart should have the same underlying risk of having ADHD. So finding a significant difference in diagnosis rates between children born only a few days apart is strong evidence of medically inappropriate diagnosis.
(Researcher) Morrill explains that the study shows that children born just after the kindergarten cutoff date were 25 percent less likely to be diagnosed as having ADHD than children born just before the cutoff date. “This indicates that there are children who are diagnosed (or not) because of something other than underlying biological or medical reasons.
“We believe that younger children may be mistakenly diagnosed as having ADHD, when in fact they are simply less mature,” Morrill says.
So basically we have diagnoses based to some degree on when a child starts school.  Uggh.  It's enough to give a parent mucho stress trying to figure out whether to send a "late birthday" child to kindergarten or hold them back, yet another swirling controversy.  I know, dealt with it personally, two times. 

Check out the revisions if you have time - including the addition of Premenstrual Dysphoric Disorder and Hyper-Sexual Disorder (Arnold, Tiger, Elliot Spitzer...).

By the way, The American Psychiatric Association wants to know what you think about the DSM proposed changes. You can add your two cents officially until June 15. 

Of course I will take all comments indefinitely.


TherExtras said...

It costs me well over $0.02 just to type $0.02! I'm often amazed at how much importance people attach to expressing their opinion - maybe they should get a blog...;)

I'm not passionate about the DSM revisions and so am grateful for a safe place to state that. Thanks, Polly!

Love this paragraph:
"But despite all the fancy new research that costs a fortune there still are no definitive biological or physiological markers of autism, ADHD, depression or any other mental disorder. We can't take a picture of the brain and make a diagnosis. We still (and hopefully always will) look to behavior for deciding what's problematic."

Sometimes I think 'behavioral medicine' is an oxymoron.


Polly Palumbo, Ph.D. said...

As usual, spot on, Barbara! Speak away. Can't say I care one way or another about the new DSM either - but it's going to make for some fun studies trying to assess changes in prevalence. So from that perspective, I'm all thumbs up over the renovations.

TherExtras said...

The DSM is kind of like a government regulation. The public input goes into the sausage-grinder and is barely recognizable when it comes back out. - One of the reasons I choose to not spend my time/money feeding the grinder.

Me, again. Barbara

Polly Palumbo, Ph.D. said...

I think I've tasted that sausage once too many times! Did I mention that I'm a vegetarian. Mostly, you know I'm not an extremist...