The biggest thing that happened this year in mental health was a dispute, practically a civil war within psychiatry. It happened because of proposed changes to the Diagnostic and Statistical Manual or DSM.

The manual describes all the disorders officially recognized by the American Psychiatric Association. It's used by psychiatrists, insurance companies, drug researchers, the courts and even schools, and it's updated roughly every 15 years.

But some of this year's proposals were not taken lightly. NPR's Alix Spiegel reports on the controversy.

ALIX SPIEGEL: In a small condo on the beach in San Diego lives a man who blames himself for what he calls the epidemic of Asperger's. The man's name is Allen Frances, and he's the guy who edited the last edition of the DSM. He's the one who put the word Asperger's in the DSM in the first place, thereby officially making it a mental disorder.

Now before Frances, there was an entry for autism, a disorder with very similar but much more severe symptoms. But Frances says doctors felt that diagnosis didn't cover the mild disorder they were actually encountering.

Dr. ALLEN FRANCES (Chairman, Diagnostic and Statistical Manual IV): Pediatricians and child psychiatrists would see kids who could talk but who had social discomfort - severe social discomfort - in a very restricted and impairing level of interests and activities, and they wanted a diagnosis for this.

SPIEGEL: A study was done to figure out how common Asperger's was, and the results were very clear: It was vanishingly rare. Then Frances put it in the DSM, and the number of kids diagnosed with the disorder exploded.

Dr. FRANCES: At that point I did an oops. This is a complete misunderstanding. It was quite distressing.

SPIEGEL: It's not that Frances doesn't think that Asperger's exists and is a real problem for some people; he does. But he also believes the diagnosis is now radically overused in a way that he and his colleagues never intended. And why, in his view, did Asperger's explode? Primarily, Allen says, because schools created a strange unintentional incentive.

Dr. FRANCES: In order to get specialized services, often one-to-one education, a child must have a diagnosis of Asperger's or some other autistic disorder. And so kids who previously might have been considered on the boundary, eccentric, socially shy, but bright and doing well in school would mainstream into regular classes. Now if they get the diagnosis of Asperger's disorder, they get into a special program where they may get $50,000 a year worth of educational services.

SPIEGEL: Frances worries that this might cause a misallocation of school resources. And Frances points to another change he made. Essentially, Frances and his colleagues made it much easier to get a diagnosis of bipolar disorder, which he says created this incredible opportunity for drug companies.

Dr. FRANCES: Drug companies got indications for treating bipolar disorder. Not just with mood stabilizers, but also with the newer antipsychotic drugs. And they began a very intensive ubiquitous advertising campaign. So the rates of bipolar disorder doubled. And lots of people got way too much antipsychotic and mood stabilizing medicines. And these aren't safe drugs.

SPIEGEL: And for Frances, the lesson of these experiences is clear. Once you put a new diagnosis in the DSM, there is no controlling what will happen to it. So there's only one thing to do.

Dr. FRANCES: Anticipate the worst. If something can be misused, it will be misused. If diagnosis can lead to overdiagnosis and over treatment, that will happen. So you have to be very, very cautious in making changes that may open the door for a flood of fad diagnoses.

SPIEGEL: As far as Frances is concerned, the new DSM is proposing too many diagnoses that are written in too broad a way, which means that ultimately a huge number of new people will be categorized as mentally ill.

But William Carpenter, one of the people behind the new DSM, disagrees. Carpenter works with the sickest of the sick at the Maryland Psychiatric Research Center. And from where he sits, this issue of overdiagnosis is a minor affair.

(Soundbite of music)

An endless stream of Christmas favorites float over the radio in a waiting room of the Research Institute.

All around this waiting room, people suffering from psychotic disorders sit in thick clothing, eyes wide, silently staring. These are the people that Carpenter sees day after day - people whose problems have been misidentified and mistreated for years. Which is why one of the changes that Carpenter has proposed for the new DSM is a diagnosis he thinks will help identify people with psychosis when they are in the very earliest stages of their disease.

Dr. WILLIAM CARPENTER (Editor, Diagnostic and Statistical Manual V): If it identifies a lot of people who otherwise would not be identified, then I would think that would be a positive good.

SPIEGEL: You see, Carpenter believes that putting this new diagnosis in the DSM will prompt research, which ultimately could produce effective treatments.

Dr. CARPENTER: So there's a potential very positive benefit. It's possible that it can make a remarkable difference in the long-term trajectory of their life.

SPIEGEL: Now, the final draft of the new DSM won't be published until 2013. In the meantime, people like Allen Frances will agitate for the number of diagnoses and their scope to be reduced. And the small group of people actually in charge of the new manual will face a difficult question of what to put in and what to leave out. �

Alix Spiegel, NPR News, Washington.

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