APA: Major Changes Loom for Bible of Mental Health

APA: Major Changes Loom for Bible of Mental Health

By John Gever, Senior Editor, MedPage Today
Published: May 19, 2009
SAN FRANCISCO, May 19 — Some familiar disorders may be dropped and diagnostic criteria for others are in line for substantial revision in the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V).Schizoaffective disorder and gender identity disorder are among those that may be on the chopping block, according to members of the working groups leading the revision who spoke here at the American Psychiatric Association annual meeting.

Perhaps more significantly, they said, DSM-V is likely to include dimensional assessments in addition to the familiar symptom checklists from past versions of the “psychiatrist’s bible.”

Since it was first published in 1952, the DSM has provided the definitive word on what is and is not mental illness, with enormous influence within medicine and on the world beyond.

The elimination of homosexuality as a mental illness in the third DSM edition issued in the 1970s, for example, is now widely viewed as a watershed development in changing society’s view from outright hostility to varying degrees of acceptance.

DSM-V is on track to be published in 2012, capping 13 years of literature reviews, commissioned research, and intensive discussions among more than 160 mental health professionals.

“Most of us involved would like a couple more years, but we know that’s not going to happen,” said David Kupfer, M.D., of the University of Pittsburgh, chairman of the task force overseeing the revision.

The 13 working groups in charge of DSM’s major subsections must still reach decisions on proposed language defining conditions and disorders. Field tests of revised diagnostic criteria are scheduled to begin this summer, with results ready for analysis in mid-2010, Dr. Kupfer said.

After further tweaking, the draft manual must be approved by the task force and ratified by the APA’s Council on Research, the Assembly, and the Board of Trustees.

Changes could be sweeping

No limits have been placed on the extent of the overhaul, explained William Narrow, M.D., the APA’s research director for DSM-V. Before the process that resulted in DSM-IV was launched, the APA had stipulated that changes be incremental.

Leaders of several work groups who spoke at a forum on Monday reported that the freedom granted this time around could indeed lead to substantial and even drastic revisions.

For example, William Carpenter, M.D., of the University of Maryland and chair of the work group on psychosis, said his team had considered moving bipolar illness into the category of psychosis rather than its current classification as a mood disorder.

But he acknowledged that such a move would face strong opposition and was unlikely. “It would happen over a number of dead bodies,” he quipped.

On the other hand, he said, “we hope to get rid of schizoaffective disorder.”

Schizoaffective disorder on the chopping block

The addition of dimensional assessments — on such features as depression, anxiety, cognitive impairment, and reality distortion, which can appear in conjunction with a wide range of psychiatric and somatic conditions — makes it possible to jettison the familiar and widely-used diagnosis, Dr. Carpenter suggested.

Patients who have previously been diagnosed with schizoaffective disorders could instead be said to have schizophrenia with a strong mood dimension.

Dr. Carpenter said his group was also likely to remove catatonia as a component of schizophrenia.

And the group was leaning heavily toward proposing a new risk syndrome for individuals — especially young people — that research has suggested are strongly predisposed to schizophrenia and other psychotic conditions.

He acknowledged, though, that there was danger in creating such a classification. It could stigmatize people diagnosed as at-risk but who don’t show overt pathology. “There are questions about how to distinguish them from the non-ill population,” Dr. Carpenter said.

He said he expected these proposals to be controversial, but when the question-and-answer period began, none of the approximately 300 people in attendance spoke against them.

“I’ll report to our work group that we had enthusiastic endorsement,” he joked.

In a similar vein, Katharine Phillips, M.D., of Brown University and Butler Hospital in Providence, R.I. — head of the anxiety conditions group — said hoarding may be added to the family of obsessive-compulsive illnesses as a separate disorder.

Genetics not ready for prime time

At the forum, and at a press briefing earlier on Monday, questions were raised about whether diagnostic criteria in DSM-V would include findings from genetic tests or neuroimaging as well as clinical presentations.

Dr. Phillips said that was not on the table, at least in her sphere. “I think at this point, it’s not clear to our work group that there are enough replicable, sensitive, specific findings from neurobiology that would allow [us] to incorporate the findings directly into diagnostic criteria,” she said.

Dr. Carpenter agreed, saying it was very unclear what to make of the gene discoveries related to schizophrenia for diagnostic purposes.

On the other hand, said Dr. Phillips, such data could inform thinking about the broad groupings of mental disorders.

Gender identity gets attention

One DSM issue that is drawing close attention from outside the psychiatric community is what to do with gender identity disorder.

The condition — in which people, often during childhood, realize that their biological gender does not match what their minds tell them — is now included in DSM-IV as a sexual dysfunction alongside pedophilia and sexual sadism.

Not surprisingly, transgender individuals and the groups representing them are lobbying hard to have gender identity disorder dropped from DSM-V.

A four-member group has been charged with developing recommendations and two of its members appeared at a separate forum here.

As described by its chairwoman, Peggy Cohen-Kettinis, Ph.D., of VU University in Amsterdam, the group is facing three main options: keep gender identity disorder approximately as it is, jettison it entirely, or change the name and diagnostic criteria.

Dr. Cohen-Kettinis said the group was nearing a decision, but both she and fellow group member Jack Drescher, M.D., a New York-based psychiatrist and prolific author on sexuality and gender, were noncommittal on which way the group was leaning.

A number of speakers at the forum represented the transgender community and most pleaded for option two.

Rebecca Allison, M.D., a Phoenix-based cardiologist and transsexual, said the ideal would be to drop the condition from DSM but keep it in the International Classification of Diseases system as a medical condition, with a name like “gender variance.”

Such a move would make it more likely that insurance companies would cover transgender transition services such as hormonal treatments and surgery, she and other speakers said.

Last year, the American Medical Association approved a resolution calling for full insurance coverage of transition services for transgender individuals — in part because of the efforts of Dr. Allison, who chairs the AMA committee on lesbian, gay, bisexual, and transgender issues.

“In a perfect world, psychiatrists could treat patients with gender variance, but not for gender variance,” she said.

Dr. Drescher argued that having gender identity disorder included in the manual’s earlier editions served a useful purpose.

In the 1970s, when it was first added, most psychiatrists considered it a neurosis or even psychosis, he said — suggesting a need for treatment and not with transition services.

He suggested that its separate identity in DSM-III and DSM-IV helped pave the way for its recognition as a physical problem rather than a psychiatric pathology.

Dr. Narrow, the research director for the DSM revision, said the process gave nearly unlimited latitude to work groups to determine diagnostic criteria that would be tested in field trials.

But he said that a recommendation to drop a disorder from DSM-V entirely would be reviewed closely at the task-force level.

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Gender Identity Disorder: Has Accepted Practice Caused Harm?

Gender Identity Disorder: Has Accepted Practice Caused Harm?
May 19, 2009
APA 2009
Lois Wingerson

As transgender activists protested outside the American Psychiatric Association (APA) meeting, speakers at the meeting were presenting on the same topic: gender identity disorder (GID). Some of their words would add clinical weight to the political slogans.

Some of the speakers are activists themselves, including Rebecca Allison, MD, cardiologist who is transgender, widely published author Sarah Hoffman, whose son is gender variant, and Hewlett-Packard engineer Kelley Winters, PhD, founder of GID Reform Advocates. Winters1 has called on the APA to use the DSM-V revision to affirm that “in the absence of dysphoria, gender identity and expression that vary from assigned birth sex are not, in themselves, grounds for diagnosing a mental disorder.”

Some mental health professionals made the same point in their own presentations. Sidney W. Ecker, MD, a former clinical professor of urology at the Georgetown University School of Medicine, Washington, DC, and chief of urology at the Washington DC VA Medical Center, was scheduled to review studies documenting that factors that influence gender identity are present before birth. While social and hormonal influences act later during childhood, he wrote, “gender identity is determined before and persists despite these effects.”2

Diane Ehrensaft, PhD, a professor at the Wright Institute in Berkeley, Calif, had a message more difficult for psychiatrists to hear. “The mental health profession has been consistently doing harm to children who are not ‘gender normal,’ and they need to retrain,” she told Psychiatric Times. Ehrensaft has specialized in therapy for foster children as well as for children with gender issues.

When she trained in the late 1960s, Ehrensaft said, the attitude of psychiatrists who taught her about such matters was that “children with gender identity issues other than normative are confused and are suffering from dysphoria” and need to be reoriented. That is “diametrically opposed” to what has been found since, she added.

To document the harm that has been done, she cited a January 2009 article in Pediatrics that found homosexual and bisexual young adults to have highly significant increases in a history of depression, illegal drug use, unprotected sex, and attempted suicide if their parents had rejected their sexual orientation.3 That study, in turn, cites numerous others over the prior decade with similar results, although none had previously examined parental rejection.

Ehrensaft said she would advise psychiatrists at her presentation that their role today is to help children understand their gender identity—which may not be what the birth certificate says—and to support rather than pathologize or malign their parents. “There’s more evidence of harm now than even 10 years ago,” she added, “and also a developing field of practice that clearly demonstrates means of helping these kids.”

Protestors are also focusing on the fact that the DSM-V Task Force on Sexual and Gender Identity Disorders is being led by Kenneth Zucker, PhD, psychologist-in-chief and head of the gender identity service in the child, youth, and family program at the Centre for Addiction and Mental Health as well as professor in the departments of psychiatry and psychology at the University of Toronto. Zucker has been on the record as saying that parents and clinicians should work to socialize very young children who behave in ways discordant with their physical gender so that they come to identify with it—but that teens who have not done so should be helped to adjust to their discordant gender identity.

A program at Children’s National Medical Center in Washington, DC, takes a different approach, offering in-person and online support groups to help families adjust to and help their children work through their own gender identity issues. Edgardo Menvielle, MD, MSHS, director of the program, was curious whether children seen in Washington have different mental health profiles than kids involved with the Toronto program. Based on Child Behavior Checklist ratings, he reported that the Washington youth showed “less pathological tendencies,” suggesting that peer support may “lessen manifestations of pathology in the child.”4

Speaking by telephone before the conference, Menvielle hastened to distance himself from that conclusion. “The implications are not very clear,” he said. “We’re dealing with a population that appears healthier overall, but it could be that we attract different families.”

Menvielle also said there is “a lot of anger about these issues,” and added, “I hope I don’t receive any tomatoes.”

Psychologist Ehrensaft said she’s eager to see studies that compare adults who received treatments intended to “normalize” their gender identities as children with those treated in more accepting environments. Meanwhile, she said, there is a move afoot to change the membership of the Task Force so that it is “more balanced.” She added that she hopes the protests do succeed in reorienting psychiatrists’ thinking about GID.

“We got homosexuality out of the DSM because of protests at the APA,” she pointed out. “Now it’s time to do the same with GID.”

1. Winters K. Beyond conundrum: strategies for diagnostic harm reduction. Abstract presented at the American Psychiatric Association Annual Meeting; May 18, 2009; San Francisco.
2. Ecker SW. Brain gender identity. Abstract presented at the American Psychiatric Association Annual Meeting; May 18, 2009; San Francisco. 3. Ryan C, Huebner D, Diaz R, Sanchez J. Family rejection as a predictor of negative health outcomes in white and latino lesbian, gay, and bisexual young adults. Pediatrics. 2009;123:346-352..
4. Menvielle EJ. Psychopathology and gender variance in a clinical sample of children. Abstract presented at the American Psychiatric Association Annual Meeting; May 18, 2009; San Francisco.

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