DSM wars: the battle to define mental illness

Gary Greenberg's feature in this month's Wired, "Inside the Battle to Define Mental Illness," is a captivating look at the controversy attending the creation of the next edition of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. Editors of previous volumes have joined with skeptics from within the profession to protest the very idea of the DSM, saying that its "diseases" bear no relation to any particular neuropathology, and instead represent (at best), handy categories to put on insurance forms, and (at worst), a bonanza for the pharma industry, who get to produce pills that "cure" any disease that's defined in the DSM. Greenberg captures the mental health field at the cusp of an enormous transformation driven by better genomics, better imaging, and hence a better understanding of what connections various symptoms have to one another, to physical problems, to genetics, and to health. The DSM has always been controversial — it's the document that turned homosexuality into a mental illness for years — but never moreso than now.

At the party, Frances and Carpenter began to talk about "psychosis risk syndrome," a diagnosis that Carpenter's group was considering for the new edition. It would apply mostly to adolescents who occasionally have jumbled thoughts, hear voices, or experience delusions. Since these kids never fully lose contact with reality, they don't qualify for any of the existing psychotic disorders. But "throughout medicine, there's a presumption that early identification and intervention is better than late," Carpenter says, citing the monitoring of cholesterol as an example. If adolescents on the brink of psychosis can be treated before a full-blown psychosis develops, he adds, "it could make a huge difference in their life story."

This new disease reminded Frances of one of his keenest regrets about the DSM-IV: its role, as he perceives it, in the epidemic of bipolar diagnoses in children over the past decade. Shortly after the book came out, doctors began to declare children bipolar even if they had never had a manic episode and were too young to have shown the pattern of mood change associated with the disease. Within a dozen years, bipolar diagnoses among children had increased 40-fold. Many of these kids were put on antipsychotic drugs, whose effects on the developing brain are poorly understood but which are known to cause obesity and diabetes. In 2007, a series of investigative reports revealed that an influential advocate for diagnosing bipolar disorder in kids, the Harvard psychiatrist Joseph Biederman, failed to disclose money he'd received from Johnson & Johnson, makers of the bipolar drug Risperdal, or risperidone. (The New York Times reported that Biederman told the company his proposed trial of Risperdal in young children "will support the safety and effectiveness of risperidone in this age group.") Frances believes this bipolar "fad" would not have occurred had the DSM-IV committee not rejected a move to limit the diagnosis to adults.