The proposed revisions of the Diagnostic and Statistical Manual of
Mental Disorders (DSM) have spurred debate over what illnesses to
include in the essential psychiatric handbook. Everything from gender
identity disorder to childhood mood swings has come under fire, and it's
not the first time. The history of psychiatry is littered with
impassioned fights over controversial diagnoses.
Gender identity disorder
Perhaps the most controversial of all current DSM disorders is <a href="http://www.livescience.com/culture/090618-sos-transgender.html">gender
identity</a> disorder. Under the DSM-IV, people who feel that their
physical gender does not match their true gender are diagnosed with
gender identity disorder (GID). The DSM-5 proposals would revise the
criteria for the disorder and change the name to the less-stigmatizing
But to many, the DSM changes don't go far enough.
"To have gender incongruence in the DSM-5, as they've defined it,
still leaves it open to a child being sent to be 'fixed' when a child
doesn't have any problems," said Diane Ehrensaft, a clinical
psychologist in Oakland, Calif., who specializes in gender identity
issues in children.
In fact, the largest controversy over GID is about an area the DSM
doesn't cover: treatment. Should kids who feel gender mismatched be
allowed to define themselves, or should they be encouraged to identify
with their physical gender? Those who argue for the latter see their
role as helping kids get comfortable in their own skin. Those who argue
for letting the child take the lead, like Ehrensaft, say that forcing a
kid to live as an unwanted gender causes <a href="http://www.livescience.com/health/090911-7-bad-thoughts.html">depression
Therapies like Ehrensaft's are relatively new, so there are no
long-term studies comparing the two approaches. When it comes to
examining differences in how the kids turn out, "We don't know," said
Kenneth Zucker, a University of Toronto psychologist who advocates
teaching kids to identify with their physical gender. "We should know in
another 10 years."
According to the Society for the Advancement of Sexual Health, <a href="http://www.livescience.com/culture/tiger-woods-sex-addiction-100218.html">sex
addiction</a> is marked by a lack of control over one's sexual
behavior. Sex addicts pursue sex despite negative consequences, can't
set boundaries and obsess over sex even when they don't want to think
about it. Self-described addicts report that they get no pleasure from
their <a href="http://www.livescience.com/health/090409-top10-sex-statistics.html">sexual
behaviors</a>, only shame.
This disorder has yet to darken the pages of the DSM, and it likely
won't be included in the DSM-5, either. Instead, the APA is recommending
the addition of a new sexual disorder called hypersexual disorder,
which doesn't describe sex as an addiction, but could fit many people
who are in treatment.</p>
In perhaps the most famous psychiatric controversy of all, the APA
did away with <a href="http://www.livescience.com/health/080617-hereditary-homosexuality.html">homosexuality</a>
as a mental disorder in 1973 after much protest by gay and lesbian
activists. The change wasn't easy, but the weight of the scientific
evidence suggested that same-sex attraction was a normal variant of
sexuality among well-adjusted people.
Still, the APA included a diagnosis in the 1980 DSM-III called
ego-dystonic homosexuality. This category was a compromise with
psychiatrists who insisted that some gays and lesbians came to them
looking for treatment. "This revision in the nomenclature provides the
possibility of finding a homosexual to be free of psychiatric disorder,
and provides a means to diagnose a mental disorder whose central feature
is conflict about homosexual behavior," explained Robert Spitzer, a
member of the APA's task force, in a 1973 position statement.
But ego-dystonic homosexuality was short-lived. The category didn't
make sense to many psychiatrists, who argued that anxiety over sexual
orientation could fit into already-existing categories, according to UC
Davis psychologist Gregory Herek. In 1986, ego-dystonic homosexuality
disappeared from the DSM.
In 1994, Asperger's disorder, which is marked by normal intelligence
and language abilities but <a href="http://www.livescience.com/culture/children-social-rejection-100202.html">poor
social skills</a>, made the DSM-IV. When the DSM-5 is published in
2013, the disorder may get the boot.
The reason? Research on Asperger's and high-functioning autism has
failed to find a difference between the two diagnoses. Overlap between
the two disorders is rampant (up to 44 percent of kids diagnosed with
Asperger's or "other autism spectrum" labels actually met the criteria
for high-functioning autism, according to a 2008 survey). If the
proposed changes are adopted, people with Asperger's will be
reclassified as having high-functioning autism.
But some Asperger's advocates disapprove. The high-functioning autism
label doesn't always fit people with Asperger's, said Dania Jekel, the
executive director of the Asperger's Association of New England, which
opposes the change.
"People with Asperger's are going to be missed," Jekel said.
Childhood bipolar disorder
If diagnosing adults with a childhood disorder is controversial, so
is diagnosing children with a disorder once thought to occur mainly in
adults. Bipolar disorder, which is characterized by mood swings between
depression and excitability, recently skyrocketed as a childhood
disorder. Between 1994 and 2003, the number of doctor visits associated
with childhood <a href="http://www.livescience.com/health/080826-insanity-evolved.html">bipolar
disorders</a> went up 40-fold, according to a 2007 study in the journal
Archives of General Psychiatry.
The problem, according to the APA, is that at least some of that
increase is due to changes in the way psychiatrists diagnose bipolar in
kids, not an actual increase in cases. To correct the issue, the APA is
considering changes to the current bipolar criteria, as well as the
addition of a new disorder, temper dysregulation with dysphoria. That
disorder would apply to kids with persistent irritable moods and
frequent <a href="http://www.livescience.com/history/080222-hn-tantrum.html">temper
tantrums</a>, but has already drawn skepticism from some who believe it
pathologizes normal kid behavior.
Attention deficit hyperactivity disorder is a well-known childhood
diagnosis. Kids with ADHD have trouble sitting still, paying attention
and controlling their impulses. Only recently, however, have
psychiatrists begun to diagnose ADHD in adults.
But just as <a href="http://www.livescience.com/health/adhd-girls-mood-problems-100226.html">ADHD
in children</a> was criticized as over-diagnosed, so is adult ADHD. A
common accusation is that psychiatrists are conspiring with
pharmaceutical companies to sell more ADHD drugs, writes New York
University psychiatrist Norman Sussman in a March 2010 editorial in
Psychiatry Weekly. However, adult ADHD is here to stay, Sussma writes:
"The benefits of pharmacologic and behavioral therapies are
Dissociative identity disorder
Once known as multiple personality disorder, dissociative identity
disorder was made famous by the book "Sybil" (Independent Pub Group,
1973), which was made into a movie of the same name in 1976. The film
and book told the story of Shirley Mason, pseudonym Sybil, who was
diagnosed as having 16 separate personalities as a result of physical
and sexual abuse by her mother.
The book and the movie were hits, but the diagnosis soon came under
fire. In 1995, psychiatrist Herbert Spiegel, who consulted on Mason's
case, told the "New York Review of Books" that he believed Mason's
"personalities" were created by her therapist, who — perhaps unwittingly
— suggested that Mason's different emotional states were distinct
personalities with names. Likewise, critics of the dissociative identity
diagnosis argue that the disorder is artificial, perpetuated by
well-meaning therapists who convince troubled and suggestible patients
that their problems are due to multiple personalities.
Nonetheless, dissociative identity disorder has weathered this
criticism and won't undergo any major changes in the DSM-5.
Narcissistic personality disorder
Someone with an <a href="http://www.livescience.com/culture/080926-facebook-narcissism.html">inflated
ego</a>, need for constant praise and lack of empathy for others might
sound like a shoe-in for psychotherapy. But the introduction of
narcissistic personality disorder into the DSM in 1980 was not without
The biggest problem was that no one could agree on who had the
disorder. Up to half of people diagnosed with a narcissistic personality
also met the criteria for other personality disorders, like histrionic
personality disorder or borderline personality disorder, according to a
2001 review in the Journal of Mental Health Counseling. Which diagnosis
they got seemed almost arbitrary.
To solve the problem, the American Psychiatric Association has
proposed big changes to the personality disorder section of the DSM-5 in
2010. The new edition would move away from specific personality
disorders to a system of dysfunctional types and traits. The idea,
according to the APA, is to cut out the overlap and create categories
that would be useful for patients who have personality problems, not
just full-blown disorders.
Sigmund Freud revolutionized psychiatry in the late 1800s and early
1900s with his theories on the unconscious state, talk therapy and
psychosexual development. Nowadays, many of these theories — like his
conclusion that young girls' sexual development is driven by jealousy
over lack of a penis and <a href="http://www.livescience.com/culture/080902-face-parents.html">sexual
desire for their father</a> — seem outdated.
But not everyone has consigned Freud to the dust heap. Organizations
like the American Psychoanalytic Association still practice and promote
Freudian-style psychoanalysis, and groups like the International
Neuropsychoanalysis Society try to combine cutting-edge neuroscience
research with Freud's century-old theories. How successful they'll be is
unknown: A 2008 study in the Journal of the American Psychoanalytic
Association found that today's psychology departments rarely teach
In the Victorian era, hysteria was a catch-all diagnosis for women in
distress. The symptoms were vague (discontentment, weakness, outbursts
of emotion, nerves) and the history sexist (Plato blamed the wanderings
of an "unfruitful" uterus).
The treatment for hysteria? "Hysterical paroxysm," also known as <a href="http://www.livescience.com/health/top10_aphrodisiacs.html">orgasm</a>.
Physicians would massage their patients' genitals either manually or
with a vibrator, a task they found tedious but surprisingly
uncontroversial. More contentious was the practice of putting
"hysterical" women on bed rest or demanding that they not work or
socialize, a treatment that often worsened anxiety or depression.
According to a 2002 editorial in the journal Spinal Cord, the
diagnosis of hysteria gradually petered out throughout the 20th century.
By 1980, hysteria disappeared from the DSM in favor of newer diagnoses
like conversion and dissociative disorders.