Dispute over psycho-diagnoses: what is normal?

The new edition of the diagnostic manual for mental illness in the USA is causing controversy. Experts fear that healthy people will be labeled as sick.

Sadness – if it lasts longer than two weeks, it could already be defined as depression. Picture: dpa

What is sick – and what is still healthy or normal? The new psychiatric manual from the United States will not be available until mid-May, but the dispute over it has been simmering for years. The American Psychiatric Association (APA) wants to officially publish the guide to mental disorders (DSM-5) at its annual meeting. Hundreds of experts, including some Germans, have worked on it for more than a decade, putting the classification of depression, anxiety or schizophrenia to the test. The DSM was first published in 1952.

Critics such as the U.S. psychiatrist Allen Frances warn that new diagnoses are now being introduced without sufficient scientific evidence and inadequate practical tests. The emeritus professor was largely responsible for the work on the predecessor DSM-IV (1994). Since then, in his view, there have been "three new false epidemics" in children: Autism, attention deficit disorder, and bipolar disorder.

"One in five U.S. adults takes at least one medication for a psychiatric condition," Frances writes in his book, "Normal – Countering the Inflation of Psychiatric Diagnoses."

Some conditions make new appearances in the DSM-5, such as "affective dysregulation," for young children who regularly display behavioral outbursts. Under "minor neurocognitive disorder," declining memory performance in old age is recorded as a disease. Asperger’s syndrome, on the other hand – a form of autism – is classified differently in the new manual. But what does this mean for German patients?

"For Germany, the publication of the DSM-5 in May will have no immediate impact, because doctors and psychologists bill according to the diagnosis code of the World Health Organization, the ICD-10," says Hamburg-based Professor Rainer Richter, president of the Federal Chamber of Psychotherapists.

But ICD-10 is also being revised, he adds, and it cannot be ruled out that diagnoses based on the U.S. model will be incorporated into ICD-11. "We have to follow this development carefully, especially when it comes to creating a version that is valid for Germany." The DSM is also recognized primarily as a basis for research.

Increasing medicalization feared

In a statement, the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN) also pleads "not to increase the number of diagnoses by adding new, milder disorders – for which, in particular, there are no therapies". The board expresses concern that this could lead to a "medicalization of problems in our society" and also "to a neglect of medical care for people with serious mental illnesses."

However, the DGPPN adds that the manual also contains necessary adjustments in the diagnostic system that "should not be rejected in principle." And the society welcomes the fact that some symptoms were not included in the DSM-5. These include, among others, burnout syndrome.

Critic Frances writes that in the USA, 80 percent of all psychotropic drugs are now prescribed by general practitioners and diagnoses are often made hastily. In Germany, the prescription figures are somewhat different: "Depending on which figures you use as a basis and which psychotropic drugs you include, about a third to slightly more than half of these drugs are prescribed by general practitioners," says Professor Wilhelm-Bernhard Niebling, a general practitioner and board member of the Drug Commission of the German Medical Association.

Involving primary care physicians

About 50,000 family physicians would be compared to about 6,000 classic neurologists and psychiatrists. "We assume from the system that family physicians, for example, recognize depression and have to be involved in care." And so the debate about DSM-5 also resonates with the question of who should actually treat the mentally ill.

The professional associations will keep a particularly close eye on a new DSM diagnosis: According to it, grief lasting more than two weeks can already be assigned to the disease depression, which could be accompanied by treatment – including antidepressants.

According to the 2012 Drug Prescription Report, the number of "defined daily doses" of antidepressants prescribed in Germany had already more than doubled in the previous ten years. Frances is also sharply critical of this innovation. His appeal at the end of his book: "Normality is worth every rescue attempt. So is psychiatry."

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