The American Psychiatric Association has
href="http://www.dsm5.org/Pages/Default.aspx">gone public with the
details
of their proposed revisions to their Diagnostic and Statistical
Manual. As expected, most of this is bland and not worthy of
attention from the general public.
Unfortunately, as
href="http://www.nytimes.com/2010/02/10/health/10psych.html?hp">Benedict
Carey points out, the book often is used for purposes other than
those for which it is intended, which can lead to unintended
consequences. It remains to be seen what these will be.
I'm just going to make some quick, admittedly superficial
comments.
First, I wince at the new category for autism:
href="http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=94">Autism
Spectrum Disorder:
Must meet criteria 1, 2, and 3:
1. Clinically significant, persistent deficits in social
communication and interactions, as manifest by all of the following:
a. Marked deficits in nonverbal and verbal
communication used for social interaction:
b. Lack of social reciprocity;
c. Failure to develop and maintain peer relationships appropriate
to developmental level
2. Restricted, repetitive patterns of behavior, interests, and
activities, as manifested by at least TWO of the following:
a. Stereotyped motor or verbal behaviors, or
unusual sensory behaviors
b. Excessive adherence to routines and ritualized patterns of
behavior
c. Restricted, fixated interests
3. Symptoms must be present in early childhood (but may not
become fully manifest until social demands exceed limited capacities)
I have no objection to the criteria. What bothers me is the
formal enshrinement of the term "spectrum." Granted, it merely
denotes a trend in modern thought, but it is a trend that ought to
remain in the informal domain for now.
Next,
href="http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=396">Posttraumatic
Stress Disorder in Preschool Children. The text is long
enough that I'm not going to copy it here. This is important
because we've known for a long time that the features are different in
kids, but there hasn't been any formal way to handle this.
Finally,
href="http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=397">Temper
Dysregulation Disorder with Dysphoria. This is bound to cause
a few tantrums. I'll guess that some will criticize this for
unnecessarily pathologizing normal childhood behavior. But the
intention is quite the opposite. Currently, there are kids who
are being labeled as having bipolar disorder, when it really is not
clear that they have bipolar disorder. So the idea is to lessen
the overuse of the more severe category. This is to be considered
a disorder of childhood and adolescence. However, there is no
rigid upper age limit. Still, I think this label is less likely
to follow a person into adulthood, whereas the bipolar disorder label
is likely to do so.
Overall, my impression is that there is more good than bad in the
proposed changes.
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Of the three proposed changes that you highlight, I think that by far the most important is "Temper Dysregulation with Dysphoria". It is high time that the APA dispense with the peremptory and facile diagnosis of Bipolar Disorder in children. I have personally witnessed, on too many occasions, the assignment of this diagnosis by psychiatrists either too lazy or ignorant to acknowledge that the problems seen in many of these kids are behavioral, or psychosocial, in nature, and not due to Bipolar Disorder. The diagnosis of Bipolar Disorder in these children does, as you say, unfortunately follow them into adulthood, but, since these individuals never met the criteria for the diagnosis of Bipolar Disorder in the first place, the impact of their situation promotes and informs a logical tautology, in which the proper and appropriate understanding of true Bipolar Disorder (in adulthood) becomes distorted by the presentation of these "false" Bipolar patients. In my current practice, I routinely run across patients labeled with some variant of Bipolar Disorder (eg, "rapid-cycling Bipolar Type II") by, typically, hospital psychiatrists who see the patient only during a brief clinical snapshot, without sufficient time or background information to justify diagnostic confidence. Frequently it turns out that these patients meet criteria for Borderline, Narcissistic or Histrionic Personality Disorder, or for PTSD or a primary substance problem. Sheer laziness on the part of our colleagues.
When I was in high school, my younger sister was handed a diagnosis of bipolar II. As I have progressed through my undergrad, a sneaking suspicion has been growing that she is not bipolar. I suppose I could consider her to be an example of one of these misdiagnoses. I'm glad something is being done, either way.
If children are being misdiagnosed with bipolar disorder, why not clarify the criteria for bipolar disorder to specifically exclude the children that don't belong there?
the criteria are already pretty clear. take a look at the current criteria in DSM-IV-TR, and you'll see.