Some psychiatrists want to add extreme bitterness to DSM as mental illness

From Canwest News Service:

Bitterness should be classified an official brain illness, according to psychiatrists who say people who experience prolonged bitterness over a breakup or conflict at work are "ill" and need treatment.

They are proposing that “post traumatic embitterment disorder” be included in the Diagnostic and Statistical Manual of Mental Disorders, psychiatry’s official catalogue of mental dysfunction.

Now in its fourth edition, DSM is undergoing its first major revision since 1994. DSM-V is due to be published in 2012, and other possible new contenders for inclusion include Internet addiction disorder, apathy disorder, compulsive buying disorder, compulsive pathological overeating, hoarding, “premenstrual dysphoric disorder” and “partner relational problem” — “a pattern of interaction between spouses or partners characterized by negative communication (criticisms, for example), distorted communications (such as unrealistic expectations) or non-communication (withdrawal).”

Working groups composed of more than 120 scientific researchers and clinicians are drafting diagnostic criteria for mood disorders, anxiety disorders,

personality disorders and psychoses. They’re deciding which disorders should be included, revised or removed. Field tests of new diagnostic criteria are due to begin this summer.

With each revision comes new disorders. The manual — as influential in Canada as it is worldwide — listed 112 disorders when first published in 1952. The most recent issue contains 374, and runs 886 pages.

As the number of diagnoses grows, so too does the chorus from critics that the book pathologizes behaviour that’s within the normal spectrum.

Post-traumatic embitterment disorder is described as a pathological reaction to a single, negative life event, such as conflict at work, unemployment, divorce, illness or separation. People view the event as unjust, a violation of their basic beliefs and values, and "want the world to see how badly they have been treated," according to published studies.

“People feel wronged, humiliated and that some injustice has been done to them,” says Dr. Michael Linden, the German psychiatrist who named the behaviour after reporting an increase in affected patients in the wake of German reunification.

“The critical part is this lasting and very intensive emotional embitterment, a mixture of depression and helplessness and hopelessness. . . . It’s a very nasty emotion.”

People have intrusive thoughts and memories about the event, and get locked into a serious mental state, he says. “These people don’t have the feeling that they must change, but rather have the idea that the world should change or the oppressor should change, so they don’t ask for treatment.”

Ten years of research suggests it affects one to two per cent of the population, but Linden says the incidence rises during times of societal change — including economic upheaval. "We are all vulnerable in those areas which are especially important to us. So, if you really think your job is the centre of your life, that’s where you’re vulnerable."

He says adding severe embitterment to the manual of mental illness could help patients get help and encourage research into the disorder.

But some critics question just how doctors could distinguish between irrational and reasonable bitterness.

Christopher Lane, a professor of literature at Northwestern University and author of Shyness: How Normal Behavior Becomes a Sickness, says it’s one thing to try to reach “that fraction of the profoundly disaffected which snaps suddenly and commits desperate crimes as a result.”

But Lane says embitterness overlaps with other disorders in the DSM, including “intermittent explosive disorder,” and that adding a separate DSM code for it would make it “almost impossible to distinguish the acutely stressed from the vast majority of the population that bears grudges or is simply justifiably angry about the current state of the country.”

In his blog for Psychology Today, Lane writes: “Imagine, if you will, the inevitable ads: ‘Think it’s just bitterness from job loss, foreclosure on your home, or that nonexistent pension for which you’ve been saving all your working years? It may be post-traumatic embitterment disorder, a mental illness that some doctors think is due to a chemical imbalance . . .’ ”

The disorder could be added to the appendix of the next edition of DSM as a sickness worthy of further study, joining such others as caffeine withdrawal and premenstrual dysphoric disorder, or PMDD. The guidebook says a woman may be experiencing PMDD if she has five out of 11 symptoms that include anxiety, feeling “keyed up” or “on edge.” Some experts are now advocating PMDD be formally classified a mental disorder.

“There’s a sizable amount of literature pushing back against it, saying there is astonishingly flimsy evidence for this and that it’s a catastrophic mistake to represent it as a form of depression,” Lane said in an interview.

Apathy disorder also has been suggested for inclusion in the DMS. Experts have argued apathy can occur alone, or in conjunction with such other conditions as Huntington’s disease, Alzheimer’s, Parkinson’s and stroke. It is also a side-effect of antidepressants, sedatives and other psychotropic drugs.

“The obvious situation there would be to scale back the number of psychotropics people are taking, not to pathologize the side-effects from those drugs,” Lane says.

Adding apathy disorder to the psychiatry manual’s mental problems would introduce “the everyday vernacular sense of being indolent or lazy,” he says.

Relational disorder risks being so open-ended and broadly defined that almost every relationship could theoretically fall under it. “It could become simply a pattern of failed relationships owing to disturbances in the brain,” says Lane.

Task force and work group members have had to sign confidentiality agreements prohibiting them from divulging confidential information about the revision process. “The secrecy makes the scenario imaginable that (relational disorders) could simply appear in 2012 with a set of symptoms that would be mind-bogglingly expansive,” Lane says.