Avoiding cliches?
Fanny Jiménez and Christiane Löll

"This is the saddest moment in my 45-year career as a psychiatrist..." Dr. Allen Frances wrote this in a December blog post on the Psychology Today website. The reason was the approval by the American Psychiatric Association (APA) of the new edition of psychiatry’s bible – Diagnostic and Statistical Manual of Mental Disorders, or DSM – the handbook that doctors and psychotherapists worldwide use to determine mental illness.

In May, DSM-5 – the first revised edition since 1994 – is due to be published in the United States. And Allen Frances’s verdict about it has clout – he was the chair of the DSM-4 Task Force. His advice to clinicians, the press and the general public is to remain skeptical about DSM-5: “don’t follow it blindly.”

Over 1,500 experts from 39 countries have spent the last 14 years working on improving the classifications so that superfluous or imprecise diagnoses can be avoided and with them the wrong medication or therapy.

The new edition features new disorders, such Minor Neurocognitive Disorder – that can presage dementia, or eating and gambling addictions that for the first time link addiction to other sources than mind altering substances.

Other disorders have been left out – like Rett Syndrome, a neurodevelopmental disorder. The diagnostic criteria for many other illnesses have been changed. Autism for example will no longer be listed as a spectrum of many separate conditions so that, as of May, Asperger’s Syndrome will no longer exist.

All of this is the result of a great deal of hard work and discussion on the part of contributing experts, resulting in many different drafts of the manual before the APA signed off on the latest edition. The subject of sex addiction was particularly controversial – at first it was going to be included among behavioral addictions, then as a whole new illness called hypersexual disorder, and finally it was dropped because scientific evidence to support it was too slim.

According to the APA, the number of mental illnesses in the new edition remains the same and there are only a few fundamental changes. However, critics maintain that some diagnoses have been watered down and that changes are not based on sufficient scientific evidence.

These experts fear that DSM-5 will turn many healthy individuals into patients, and will limit treatment of certain diagnoses like autism. Fred Volkmar of Yale University estimates that only 60% of those who would get an autism diagnosis today will get it in the future.

Frances agrees that with the exception of autism, all the changes in the new edition will turn the “current diagnostic inflation into diagnostic hyperinflation” – something that could have dire consequences, given the global importance of the manual.

Temper tantrums as mental disorder

"The DSM is the standard reference book worldwide; research and treatments are based on it. It is also used as a reference in court cases and by insurance companies," says Winfried Rief of the University of Marburg, one of the experts involved in producing DSM-5. German doctors also use the World Health Organization (WHO) International Classification of Diseases, the present edition of which (ICD-10) is due for an overhaul in 2015.

Hans-Ulrich Wittchen of Dresden’s University of Technology, who also worked on DSM-5, says he does not believe the new version will lead to increased numbers of diagnoses. "No changes are to be expected because the criteria were only changed marginally," he explains, adding that "even the new disorders will most likely not impact the total number of patients because most patients suffering from conditions added to DSM-5 usually have other disturbances listed in earlier editions."

But Frances is adamant that the new edition is going to bring with it a dramatic rise in the number of mental illness diagnoses, particularly – as “painful experience” with previous editions has shown – if anything in the diagnostic system is abused and turned into a “fad.”

The conflict demonstrates just how difficult it is to classify mental illness. A case in point is what DSM-5 lists as "disruptive mood dysregulation disorder" in children. On Frances’s list of the ten worst changes from the previous edition, this condition is ranked number one.

According to the APA, this diagnosis applies to children who display disruptive patterns three or more times a week for at least a year, and it is supposed to help check over-diagnosis and over-treatment of bipolar disorder in children. But Frances charges that what it amounts to is turning “temper tantrums into a mental disorder.” His own book, SAVING NORMAL: The Battle at the Boundary of Psychiatry is due out around the same time as DSM-5.

What is clear is that there are no definitive answers – or answers that will satisfy everyone. Says Wittchen: "Diagnostics never end – many problems have yet to be resolved because we don’t yet know enough about how the brain works. Breakthroughs in neurobiological research could mean a whole new set of diagnoses. And then we get to start from scratch.”

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Economy

European Debt? The First Question For Merkel's Successor

Across southern Europe, all eyes are on the German elections, as they hope a change of government might bring about reforms to the EU Stability Pact.

Angela Merkel at a campaign event of CDU party, Stralsund, Sep 2021

Tobias Kaiser, Virginia Kirst, Martina Meister


-Analysis-

BERLIN — Finance Minister Olaf Scholz (SPD) is the front-runner, according to recent polls, to become Germany's next chancellor. Little wonder then that he's attracting attention not just within the country, but from neighbors across Europe who are watching and listening to his every word.

That was certainly the case this past weekend in Brdo, Slovenia, where the minister met with his European counterparts. And of particular interest for those in attendance is where Scholz stands on the issue of debt-rule reform for the eurozone, a subject that is expected to be hotly debated among EU members in the coming months.

France, which holds its own elections early next year, has already made its position clear. "When it comes to the Stability and Growth Pact, we need new rules," said Bruno Le Maire, France's minister of the economy and finance, at the meeting in Slovenia. "We need simpler rules that take the economic reality into account. That is what France will be arguing for in the coming weeks."

The economic reality for eurozone countries is an average national debt of 100% of GDP. Only Luxemburg is currently meeting the two central requirements of the Maastricht Treaty: That national debt must be less than 60% of GDP and the deficit should be no more than 3%. For the moment, these rules have been set aside due to the coronavirus crisis, but next year national leaders must decide how to go forward and whether the rules should be reinstated in 2023.

Europe's north-south divide lives on

The debate looks set to be intense. Fiscally conservative countries, above all Austria and the Netherlands, are against relaxing the rules as they recently made very clear in a joint position paper on the subject. In contrast, southern European countries that are dealing with high levels of national debt believe that now is the moment to relax the rules.

Those governments are calling for countries to be given more freedom over their levels of national debt so that the economy, which is recovering remarkably quickly thanks to coronavirus spending and the European Central Bank's relaxation of its fiscal policy, can continue to grow.

Despite its clear stance on the issue, Paris hasn't yet gone on the offensive.

The rules must be "adapted to fit the new reality," said Spanish Finance Minister Nadia Calviño in Brdo. She says the eurozone needs "new rules that work." Her Belgian counterpart agreed. The national debts in both countries currently stand at over 100% of GDP. The same is true of France, Italy, Portugal, Greece and Cyprus.

Officials there will be keeping a close eye on the German elections — and the subsequent coalition negotiations. Along with France, Germany still sets the tone in the EU, and Berlin's stance on the brewing conflict will depend largely on what the coalition government looks like.

A key question is which party Germany's next finance minister comes from. In their election campaign, the Greens have called for the debt rules to be revised so that in the future they support rather than hinder public investment. The FDP, however, wants to reinstate the Maastricht Treaty rules exactly as they were and ensure they are more strictly enforced than before.

This demand is unlikely to gain traction at the EU level because too many countries would still be breaking the rules for years to come. There is already a consensus that they should be reformed; what is still at stake is how far these reforms should go.

Mario Draghi on stage in Bologna

Prime Minister Mario Draghi at an event in Bologna, Italy — Photo: Brancolini/ROPI/ZUMA

Time for Draghi to step up?

Despite its clear stance on the issue, Paris hasn't yet gone on the offensive. That having been said, starting in January, France will take over the presidency of the EU Council for a period that will coincide with its presidential election campaign. And it's likely that Macron's main rival, right-wing populist Marine Le Pen, will put the reforms front and center, especially since she has long argued against Germany and in favor of more freedom.

Rome is putting its faith in the negotiating skills of Prime Minister Mario Draghi, a former head of the European Central Bank. Draghi is a respected EU finance expert at the debating table and can be of great service to Italy precisely at a moment when Merkel's departure may see Germany represented by a politician with less experience at these kinds of drawn-out summits, where discussions go on long into the night.

The Stability and Growth pact may survive unscathed.

Regardless of how heated the debates turn out to be, the Stability and Growth Pact may well survive the conflict unscathed, as its symbolic value may make revising the agreement itself practically impossible. Instead, the aim will be to rewrite the rules that govern how the Pact should be interpreted: regulations, in other words, about how the deficit and national debt should be calculated.

One possible change would be to allow future borrowing for environmental investments to be discounted. France is not alone in calling for that. European Commissioner for Economy Paolo Gentiloni has also added his voice.

The European Commission is assuming that the debate may drag on for some time. The rules — set aside during the pandemic — are supposed to come into force again at the start of 2023.

The Commission is already preparing for the possibility that they could be reactivated without any reforms. They are investigating how the flexibility that has already been built into the debt laws could be used to ensure that a large swathe of eurozone countries don't automatically find themselves contravening them, representatives explained.

The Commission will present its recommendations for reforms, which will serve as a basis for the countries' negotiations, in December. By that point, the results of the German elections will be known, as well as possibly the coalition negotiations. And we might have a clearer idea of how intense the fight over Europe's debt rules could become — and whether the hopes of the southern countries could become reality.

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