Guidelines Debated for Mental Disorders Proposed New Definitions Could Alter Diagnosis

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When Brent Robbins was a boy, he said, "I was an odd kid. I was a bit of a clown." And after one of his episodes of showing off, he recalled, "my teachers demanded my parents take me to a psychiatrist."

Luckily, said the head of the psychology program at Point Park University, "they happened to take me to someone who said, 'Oh, he's a wonderful kid. He'll never quite fit in, but he's fine.' And by the time I was in college, I was flourishing and had found my niche."

Those experiences have made him wary of anyone today who wants to label an eccentric child as mentally ill, and it's one of the reasons he has become a national leader of a movement that is raising questions about the American Psychiatric Association's attempt to create an updated "bible" of mental disorders.

As a representative of the Society for Humanistic Psychology, Mr. Robbins has been instrumental in drafting a critical letter to the task force revising the Diagnostic and Statistical Manual of Mental Disorders. The letter already has attracted more than 10,000 signatures of support, most from mental health professionals.

One of his particular concerns is a proposed new diagnosis in the DSM-5 called attenuated psychosis syndrome, which says that those who experience hallucinations or delusions may be at risk of later developing a full-blown psychosis.

Some studies have shown that only about 20 percent of adolescents who exhibit these symptoms later develop schizophrenia, though, and Mr. Robbins worries that the inclusion of this diagnosis in the manual could unfairly label many teens as mentally ill and put them on a regimen of heavy-duty psychotropic drugs.

"My concern here is that a lot of people who may just be eccentric or unusual might turn out to be wonderful, gifted people. Imagine what Salvador Dali or Andy Warhol were like as adolescents. Some people might have interpreted their behavior as delusional.

"I'm very concerned that you're going to have a lot of wonderful, uniquely gifted kids who instead of being appreciated will be labeled as dysfunctional."

It's just one of many objections that have been raised about the DSM-5, which is going through its final revisions and is due to be published in the spring of 2013.

The manual revision task force is being chaired by eminent UPMC psychiatrist David Kupfer, who was not available for comment.

But other leading members of the task force stressed that none of the DSM-5 proposals is final, and that all the major diagnoses are being field tested for clarity and reliability.

On the attenuated psychosis syndrome, William Narrow, research director for the DSM-5 Task Force, said that because some adolescents who show these symptoms do go on to get full-blown schizophrenia, "formal designation of an attenuated psychosis syndrome in DSM would mean a greater likelihood that clinicians will recognize the syndrome ... and be able to follow the symptoms over time and intervene when needed."

And that intervention, Dr. Narrow stressed, might include various kinds of talk therapy or treatment with omega-3 fatty acids rather than drugs. "Because of potential long-term side effects, the current practice has generally been to withhold antipsychotic medication treatments for patients with this syndrome until a full psychotic disorder emerges," he wrote.

The other new definition that bothers Mr. Robbins is one called disruptive mood dysregulation disorder, or DMDD, described as excessive temper outbursts occurring three or more times a week in children younger than 10.

Mr. Robbins said this category serves as a substitute for the earlier diagnosis of pediatric bipolar disorder, and he fears that children who get the diagnosis also may be prescribed heavy-duty psychotropic medications.

"I think there are some kids and adults who absolutely need medications," he said, "so it would be a mistake to assume we have an anti-drug message. But realistically, if you can find any other intervention, especially for children, you want to do it because drugs are a double-edged sword, because every drug has side effects. …