DSM-5: will everyday worries be medicalised into Generalized Anxiety Disorder?

DSM-5 coverOver the past three years I’ve written at length about the likely impact on TS/TG people of the revisions proposed for the forthcoming fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Although the DSM originates in the US, it is internationally recognised and the criteria it uses to categorise many medical conditions are generally adhered to worldwide. And although it is far from perfect, it also formalises access to medical services, including GPs, therapists, medication and surgery. For example, the comparatively few rights and protections that exist for people diagnosed as having Gender Identity Disorder (GID) are there mainly because they are in the DSM.

But the proposed revisions aren’t limited to the area of gender identity; far from it. From Adjustment Disorders to Eating Disorders, Mood Disorders to Substance-Related Disorders, there’s a wide range of medical conditions under review. Included in this list of categories is Generalized Anxiety Disorder, which Bruce Jancin has written about at Family Practice News. Mr Jancin suggests that the proposed changes could have a much wider impact than is perhaps realised:

Generalized anxiety disorder, already the most common of the anxiety disorders, could double in prevalence in clinical practice with adoption of changes now under consideration for the coming edition of psychiatry’s diagnostic and statistical manual, the DSM-5.

His basis for saying this is that there are two aspects of the DSM-5 proposal that would lower the threshold for the diagnosis. First, there is a reduction in the required duration of anxiety symptoms from the DSM-IV’s 6 months to just 3 months and second, the number of required associated symptoms would be only 1 out of 4, rather than the more stringent DSM-IV criterion of 3 out of 6.

Other changes under consideration include deleting sleep disturbances and irritability from the list of associated symptoms on the grounds that they are insufficiently specific. The work group also is weighing reintroduction of dimensional attributes such as anxiety and depression to serve as adjuncts to the current categorical attributes.

“If there’s any psychiatric diagnosis where a dimension is relevant, it’s GAD, where some social animals – and not only humans – are just born with a greater propensity to manifest anxiety in response to normal stimuli,” [Dr. Alan J. Gelenberg of the department of psychiatry at Pennsylvania State University] observed.

Commenting on Bruce Jancin’s article at Psychiatric Times, Allen Frances MD points out where this might lead in reality – and it makes disturbing reading:

Why is this such a bad idea? The symptoms of GAD are extremely nonspecific and very common in the general population. They merge imperceptibly into the expectable worries of every day life and the normal reactions to common stressors. There are simply no bright lines separating someone who has a real mental disorder from the normal worry wart or the person with a lot of problems that actually do need worrying about. Any rapid expansion of the diagnosis of GAD will surely capture many of these false positive individuals who do not have clinically significant symptoms that require mental health diagnosis or treatment– people who would be better off left alone without further intervention.

But the way the world works, most people who get mislabelled will likely wind up receiving medication– usually antidepressants, and sometimes the much more problematic antianxiety drugs. Mild anxiety symptoms have a very high placebo response rate (around 50%)–quite close to the response rate achieved by medication. Although the majority of patients mislabelled as having GAD will not actually need medication, they will often receive it and may feel compelled to stay on it for the long term– with all the attendant unnecessary side effects, complications, cost, and stigma.

The thing to remember that there is not a pill for every worry or life problem and that pills can sometimes make things worse. Of note, DSM-5 is also suggesting another related change that will lead to even greater diagnostic inflation–a new disorder mixing common symptoms of anxiety and depression and requiring a remarkably short duration of only 2 weeks. Taken together, the 2 changes would capture a large segment of the worried well.

But it’s the closing paragraph which resonates most strongly with me, given what I’ve seen of the way the Sexual and Gender Identity Disorders Work Group under the aegis of Ken Zucker has approached its task:

In the preparation of DSM-5, the experts on the work groups have been given far too much freedom and far too little supervision. Their suggestions for changes are supported by cursory and one sided reviews that seize on the occasional study and ignore all that is unknown or contrary. Suggested changes should have been subjected to the much more stringent standards of evidence based medicine as applied by independent reviewers. The DSM-5 field trials should have been designed specifically to study the crucial question of impact on rates, not the fairly trivial question of reliability. A searching risk/benefit analysis needs to be done on each suggestion.

What is clearly broke and cries out for fixing is the DSM-5 process itself.

I can’t help but agree with that commentary – labelling the “worried well” as “disordered” seems to me to be blatant pathologisation and, if my own experience is any guide, I would expect such a labelling to lead to social stigmatisation from many perhaps unexpected quarters. However, given that field trials to test the new diagnostic criteria have now been underway since December 2010, I for one am not optimistic about the chances of a wholescale overhaul of any of the proposals for any of the categories ahead of the full publication of the DSM-5 in May 2013.

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