Behaving badly has disorder to call its own
Ever-growing list of mental illnesses met by skepticism
By Chris Emery
Sun reporter
Originally published July 17, 2006
http://www.baltimoresun.com/news/nationworld/bal-te.anger17jul17,0,7903653.story

When researchers announced that 16 million Americans who fly into occasional fits of unwarranted rage may suffer from a mental illness called "intermittent explosive disorder," the diagnosis drew its share of hoots and howls.

"Your grandmother would say these are bad folks who can't control their temper, and she would be right," said Dr. E. Fuller Torrey, an outspoken schizophrenia expert alarmed by the ever-expanding list of behaviors and attitudes branded as illnesses.

Torrey and other critics point to the volume that doctors use to determine mental illness, the Diagnostic and Statistical Manual of Mental Disorders, as evidence that the world is out of control.

When it was first published in 1952, the DSM identified about 100 official mental disorders. Today, it certifies roughly 375.

Intermittent explosive disorder became the latest of those to reach the public consciousness in June, when a study of the syndrome, funded by the National Institutes of Health, was released.

Newspaper columnists and others around the country exploded in skepticism at its conclusions.

"Is it me, or does it seem like good old-fashioned bad behavior - rudeness, obsession, violence - is being increasingly explained away by doctors and pharmaceutical companies as some kind of mental illness du jour?" asked columnist Daniel Vasquez in the South Florida Sun-Sentinel.

In Georgia, a headline in The Augusta Chronicle read, "Jerks get disorder of their own."

While many critics echoed the derision historically reserved for mental illness, some mental health experts - including Torrey - are also skeptical.

"It's not a well-defined entity," Torrey said of IED. At the heart of his concern is a question mental health providers have long debated: When does a behavior or emotion cross the line from normal - however eccentric or undesirable - to become an illness?

What they decide affects many aspects of American life, ranging from criminal trials to decisions on who gets treatment and disability benefits for mental illness.

The most visible venue for that debate is the DSM, the primary reference for mental health professionals. When the American Psychiatric Association revises the manual every few years, doctors have to decide what disorders will be included.

Although the DSM's definitions of mental disorders are only guidelines, they influence courts, insurance companies and government agencies.

Although it was virtually unknown to the public before the June report, IED has been used as a legal defense in murder, assault and intimidation cases.

In a 1993 trial, an Oregon man who attacked his dentist during a tooth extraction appealed his assault conviction by blaming the outburst on IED. A federal court rejected the appeal, ruling that the disorder did not qualify as an insanity defense under Oregon law.

Elsewhere, patients have used the diagnosis to claim disability income from the Social Security Administration. And insurance companies are likely to pay for medications used to treat IED and other disorders listed in the manual.

Critics argue that the professionals who rule on what goes into the manual too often have ties to the pharmaceutical industry.

"The people who make these decision range from those with very good intentions ... to people who care about power, money and territory, and work hand in hand with the drug companies," said Paula J. Caplan, a psychologist and author of a book critical of the DSM.

Dr. William Narrow, the associate director of the American Psychiatric Association's Division of Research, said he was not familiar with how the DSM's 1994 edition was produced, but he noted that in 2001, five lawsuits accusing the APA of conspiring with Novartis Pharmaceuticals Corp. were either dropped or dismissed.

The suits were filed by parents of children diagnosed with attention deficit disorder and attention-deficit hyperactivity disorder. They claimed the disorders were created and put into the DSM to stimulate sales of the Novartis drug Ritalin, a common treatment for both conditions.

Narrow said the APA is taking precautions to prevent therapists with ties to drug companies from providing input on the DSM's next revision. "We want the DSM to be a scientific document that won't be questioned for conflicts of interest," he said. "There has been no overt pressure from the pharmaceutical companies."

Some psychiatrists worry that the credibility of their profession will be undermined if the guidelines are expanded too far or become too specific. In particular, they worry that fracturing well-documented disorders into sub-disorders based on flimsy evidence could prevent patients from getting appropriate treatment.

Those concerns alarmed critics when several controversial disorders were added to the manual's fourth edition, typically referred to as the DSM-IV.

"Many of us thought they went overboard," Torrey said. He joked that the range of disorders in the DSM-IV is so wide "you can fit almost everybody you know into one."

Much of the controversy surrounded personality disorders and mental illness among children. Among the most recently defined mental ailments, several drew particular scorn: mathematics disorder, reading disorder and disorder of written expression.

Based on definitions in the DSM-IV, naughty children can be diagnosed with oppositional defiant disorder and cigarette smokers with nicotine dependence. "If You're Breathing, You're In The Book," a 1994 newspaper headline in the Greensboro, N.C., News & Record declared. Another newspaper asked, "Is it True? Are We All Crazy?"

More recently, doctors have begun suggesting disorders that should be included in the next revision of the manual, due in 2011.

Caplan said one doctor is proposing a new diagnosis, relational disorder, which she summarizes as a dysfunctional relationship in which "neither person is mentally ill but the relationship is."

She said she wonders what would happen when an afflicted couple visits the doctor's office for help. "The psychiatrist takes out a pill. ... Where does the psychiatrist put it?" she asked. Other doctors have suggested broadening the definition of bipolar disorder, an illness once known as manic depression, characterized by extreme mood swings from elation to deep despair.

Under the proposed changes in the DSM, "everyone who's had any kind of mood swings in their life becomes bipolar," Torrey said. "And because of that, the concept loses meaning."

While the APA's Narrow agrees the jury is out on expanding the definition of bipolar disorder - particularly when it would enrich the drug manufacturers whose medicines are used to treat it - he argues that refining the definition of old disorders and identifying new ones is important. "It means patients are more likely to get better treatment for their disorders," he said. "An accurate diagnosis leads to an accurate treatment."

The findings of the IED study released in June support that view, according to Ronald C. Kessler, the Harvard scientist who led the research team. The researchers found that IED often appears in adolescence but is later compounded by other problems such as alcoholism and depression. Identifying and treating the anger attacks early on might help prevent the problems that boil up, he said.

The study found that over a lifetime, people with IED averaged 43 rage attacks resulting in $1,359 in property damage. "The question is, can you make them into regular people, and there is evidence we can," Kessler said.

Part of the reason for public skepticism about psychological disorders is a long-standing stigma surrounding mental illness, said Bob Corolla, a spokesman for the National Alliance for the Mentally Ill.

"There are still people who believe mental illnesses are a function of character and not illness," he said. "If you interview Tom Cruise, he might tell you that."

The movie star is a member of the Church of Scientology, which eschews psychiatric treatment, and he publicly criticized actress Brooke Shields in 2005 for taking medication for postpartum depression.

Corolla said he first learned of IED from a short-lived Fox comedy called Head Cases, in which one character, a lawyer, had the disorder.

"In a trial, he hit the other attorney in the head with a law book, and I wondered if it was even a disorder," Corolla said.

A scientist with the alliance later confirmed to him that IED was legitimate. In fact, researchers have found that the propensity for angry outbursts might be inherited - and regarded as a kind of epilepsy.

"We are not as concerned about what they call it," Corolla said. "Take the name away, you're still dealing with a set of symptoms that need treatment."