By Allan V. Horwitz
The latest revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM-5, now scheduled to be published in May 2013, has generated a tremendous amount of controversy. The DSM is published by the American Psychiatric Association to provide common language and criteria for the diagnosis of mental disorders, so any proposed changes to its terminology could mean millions more, or millions less, diagnosed with an illness. Most of the discussion centers around issues such as incorporating Asperger’s disorder, autistic disorder, and several other conditions into a single “autism spectrum disorders” category; the abandonment of the bereavement exclusion in the Major Depressive Disorder diagnosis; the creation of an at-risk category for psychotic conditions; and the development of dimensional measures for several common disorders. Nevertheless, the proposed changes in the Generalized Anxiety Disorder (GAD) have been relatively neglected.
Changes in the GAD category are potentially the most important because they would impact the largest number of people. Anxiety disorders are the single most common class of mental disorders in the population and, historically, GAD has been the central anxiety disorder. The changes that the DSM-5 anxiety working group proposes for GAD have the potential to massively increase the number of people subject to GAD diagnosis and, correspondingly, the number of people at risk for false positive diagnoses of GAD.
The DSM-III, following Freud, had defined Generalized Anxiety Disorder as a “generalized, persistent” condition that lacked the more specific symptoms characterizing the other anxiety disorders. It also made it a residual condition that couldn’t be diagnosed in the presence of other anxiety or depressive conditions, so that its actual prevalence was quite low: patients who met GAD criteria typically also met criteria for other disorders. The DSM-III-R (1986) abandoned the hierarchical rule that disallowed GAD diagnoses in the presence of other disorders. It also transformed the nature of GAD from generalized anxiety to a focus on specific worries, stating:
Unrealistic or excessive anxiety and worry (apprehensive expectation) about two or more life circumstances, e.g. worry about possible misfortune to one’s child (who is in no danger) and worry about finances (for no good reason), for a period of six months or longer, during which the person has been bothered more days than not by these concerns.
The central place this definition accords to worries not only changed the core nature of the diagnosis but also — given the omnipresence of things that people have to worry about — could potentially pathologize common anxious conditions. However, the many qualifiers such as “two or more life circumstances” and examples of limiting diagnoses to anxiety about children who are “in no danger” or about finances “for no good reason” clearly distinguished realistic worries from anxiety disorders. The DSM-III-R also required that symptoms must endure for six months, reducing the possibility that purely situational anxiety would be misdiagnosed as GAD. For the most part, the DSM-IV maintained the DSM-IIIR criteria for GAD.
The DSM-5 proposals for Generalized Anxiety Disorder run the risk of extensively pathologizing what could become an extraordinarily common disorder. They would lower the duration and severity thresholds for GAD from six to three months and from three of six to one of four symptoms, respectively. Moreover, they lack the contextual qualifiers that the DSM-IIIR had used to distinguish disordered from natural worries: “Excessive anxiety and worry (apprehensive expectation) about two (or more) domains of activities or events (for example, domains like family, health, finances, and school/work difficulties).” Worse, the types of worries these criteria specify are exactly the most common concerns in the population, so that lower thresholds have the potential to vastly increase the number of people subject to this diagnosis. The criteria leave unclear what the meaning of “excessive” is — patient self-definition, social norms, clinician judgment, etc. — so this qualifier does not provide much help in limiting false positives. Given the ubiquity of common worries in the population, these lower thresholds could pave the way for GAD to replace depression as the most common diagnosis of twenty-first century psychiatry.
In certain respects, the DSM-5 recommendations for Generalized Anxiety Disorder reverse the ages old dictum that mental disorders must be without cause, that is, not understandable in terms of the person’s actual life situation. From Hippocrates through the DSM-IV definition of mental illness, worries about family, health, finances, or work would have been excluded from the domain of mental disorders. Indeed, they are the very model of conditions that arise with cause. The DSM-5 proposals for GAD could classify even the most understandable sorts of worries as mental disorders.
Allan V. Horwitz is Board of Governors Professor of Sociology at Rutgers University. He is the author, with Jerome Wakefield, of The Loss of Sadness: How Psychiatry Transformed Ordinary Misery into Mental Disorder (Oxford University Press, 2007). His book, All We Have to Fear: Psychiatry’s Transformation of Natural Anxieties into Mental Disorders, also with Wakefield, will be published by Oxford in June 2012.