American Psychiatric Association

The World Health Organization Identifies Gaming Disorder as a Mental Health Condition

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Gaming Disorder

In 2018, the World Health Organization plans to add “gaming disorder” – characterized by a pattern of persistent or recurrent gaming behavior – to its list of mental health conditions.

According to the beta draft site, the WHO’s 11th International Classification of Diseases (ICD) defines a number of diseases, disorders, injuries and other related health conditions, which are listed in a comprehensive, hierarchical fashion. It enables the sharing of health information between countries and facilitates the analysis of “health information for evidence-based decision-making.” The previous version of the ICD was approved in 1990 by the 43rd World Health Assembly. The current draft that lists “gaming disorder,” is not final, nor does it list prevention or treatment options. The beta draft site, updated daily, is also not approved by the WHO.

The WHO’s impending beta draft for the next ICD classifies gaming disorder as a pattern of behavior with “impaired control over gaming,” in terms of its frequency, intensity, duration, and the capacity to quit. The disorder falls under the parent category of “Disorders due to addictive behaviors,” and is characterized by giving increased priority to gaming over other daily activities.

Applying to both online and offline video gaming, the condition is also defined by the “continuation or escalation of gaming despite the occurrence of negative consequences.” In order to be diagnosed, these behaviors must be evident over a period of at least 12 months, according to the draft.

A Matter of Contention

“The WHO designation is now generally in line with the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (DSM-5)’s description of internet gaming disorder (IGD),” Nancy Petry, a professor of medicine at the University of Connecticut Health Center, told Futurism. The main difference though, Petry said, is that the DSM-5 didn’t consider the data sufficient to classify IGD as a unique mental health condition. Rather, it’s categorized under “conditions for further study.”

The WHO’s decision highlights a schism among psychologists: some think the new designation is a welcome one, but others don’t see enough evidence to justify it.

Alexander Blaszczynski, a professor of clinical psychology at the University of Sydney, Australia told Futurism he is concerned about “the absence of clear diagnostic criteria determining what constitutes a gaming disorder, and the validity of applying existing addiction criteria to a behavior.” He noted that there is a range of behaviors now being identified as addictions — everything from salsa dancing, to smartphones, to in vitro fertilization. “At what point does an activity transform from an entertainment to a disorder?” he said.

The controversy ultimately reflects some deeper philosophical debates that have dogged most areas of medicine for many years, Ronald Pies, a clinical professor of psychiatry at Tufts University School of Medicine, told Futurism. “What should or should not count as “disease” or “disorder”? Do we require physiological, biochemical, or neurological “markers” of a putative disease entity in order to validate it, or is it sufficient to document substantial impairment and dysfunction in activities of daily living, responsibilities, etc., as the WHO criteria emphasize?”

Chris Ferguson, a professor of psychology at Stetson University in Florida told Futurism that he does not support the WHO’s designation. “Basically I don’t think the research is there yet to support this as a diagnosis and there is considerable risk of harm due to a “junk diagnosis.”

He said research suggests what we’re calling “gaming disorder” isn’t really a solitary diagnosis. Ferguson said some people certainly overdo gaming, as others may “overdo” or develop addictions to myriad other activities like shopping, exercise, and sex. “But the data we have suggests that usually individuals have a preexisting mental health condition like depression or anxiety first, then use these activities as coping mechanisms.”

Pies said he shared many of Ferguson’s concerns, saying he was “more skeptical than not” of the designation. “While some recent neurophysiological studies suggest that IGD may be a discrete disorder, there is still no scientific consensus on this point. It is unclear whether IGD is truly a “stand alone” condition; whether it is mostly explained by other underlying conditions, such as anxious or depressive disorders; or whether it is merely a subtype of so-called “behavioral addictions”, which are themselves sources of scientific controversy,” Pies said.

INFOGRAPHIC: Meet the Oculus Rift Games That Just Launched

Others, like Douglas Gentile, a psychology professor at Iowa State University, see this as a big step in the right direction. Gentile compared where we are with gaming “addiction” as “similar to where we were with alcoholism in the 1960s.” At that time, alcoholism was considered a moral failing — people thought ‘it’s your own damn fault,’” he told Futurism. “It took another 30 years for people to agree that a medical model for alcoholism makes sense and now people can get the help they need.”

Gentile doesn’t think our culture is ready to accept the medical model of video gaming, and still sees it as a moral failing — mostly by the children’s parents. “We have lots of people who could be helped, but aren’t being helped. If you walk into a doctor or psychiatrist’s office, they either won’t treat it or you have to pay out of pocket.”

Ferguson isn’t sure “why the WHO is so obsessed with gaming when a wide range of behaviors can be overdone.” Given that other potential addictions, like food or sex, have as much research as gaming, it seems likely that the WHO’s kneejerk reaction comes from a broader moral panic over video games and technology, he said.

But Gentile counters that the WHO’s acknowledgement that video gaming could be a problem “puts truth back on the table,” Gentile said. “We need to treat games with more respect. We play them because we want to be affected, but then say they have no effects.”

Access Is a Predictor Of Addiction

As our video game experience expands with virtual reality (VR) and augmented reality (AR), the argument gets even murkier. “One thing that we do know about addictions, generally, is that the number one predictor [for] if you’re going to become an addict is access,” said Gentile. “If you can’t get drugs, you can’t become addicted to them. Now that we’ve made gaming this ubiquitous — on phones, with gaming tech and VR tech in-house — we’ve made access open to everyone.”

Gentile isn’t certain that VR games are more addicting than their traditional counterparts. “We don’t know if greater immersion makes the games more addictive. To say that VR will be more addictive is making the argument that seeing things in three dimensions is more addictive than seeing them in two.” But he added that we don’t have the scientific evidence to support that.

Scientists do tend to agree on one thing: that the designation will ensure researchers pay more attention to the problems that can arise from excessive gaming. “It is important that people with this condition receive help, and that research progresses in a manner consistent with state of the art science applied toward other mental health conditions,” said UCONN’s Nancy Petry.

Moreover, the WHO designation could help those diagnosed with video gaming disorder in another way: if they’re able to access treatment, it could be covered by insurance. However, Ronald Pies warned that “social goods” of this sort do not amount to a scientific justification for a disease category, and even among supporters of the diagnosis, there is no consensus regarding what the effective “treatment” would be.

AMERICAN PSYCHIATRIC ASSOCIATION MAKES IT OFFICIAL: ‘SELFIE’ A MENTAL DISORDER.

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The American Psychiatric Association (APA) has officially confirmed what many people thought all along: taking ‘selfies’ is a mental disorder.

Selfitis

The APA made this classification during its annual board of directors meeting in Chicago. The disorder is called selfitis, and is defined as the obsessive compulsive desire to take photos of one’s self  and post them on social media as a way to make up for the lack of self-esteem and to fill a gap in intimacy.

APA said there are three levels of the disorder:

  • Borderline selfitis : taking photos of one’s self at least three times a day but not posting them on social media
  • Acute selfitis: taking photos of one’s self at least three times a day and posting each of the photos on social media
  • Chronic selfitis: Uncontrollable urge to take photos of one’s self  round the clock and posting the photos on social media more than six times a day

According to the APA, while there is currently no cure for the disorder, temporary treatment is available through Cognitive Behavioral Therapy (CBT).  The other good news is that CBT is covered under Obamacare.

This is unwelcome news for Makati City in the Philippines, especially for its mayor, Junjun Binay, son of the incumbent vice president.  Makati was recently named selfie capital of the world by Time Magazine. The mayor even organized a ticker tape parade after his city was bestowed the rare honor.

MORE BREAKING NEWS!! Oxford Dictionaries Announce New Words – including ‘selfitis.’

BREAKING NEWS!!  Apple, Samsung, Nokia Set To Eliminate Front-Facing Cameras From Their Smartphones.

A New Psychiatry Subspecialty?

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While onsite at the 2013 Annual Meeting of the American Psychiatric Association, Medscape spoke with Drs. Edward M. Kantor and Nolan R. Williams about the emerging new field of interventionalist psychiatry and their initiative to develop a training program.[1]

Background

Medscape: What is interventional psychiatry?

Dr. Williams: Interventional psychiatry is an emerging subspecialty that uses brain stimulation techniques to modulate the dysfunctional circuitry underlying medically resistant psychiatric diseases. Physicians who deliver procedures in the spectrum between standard care and surgery are sometimes referred to as “interventionalists” in other areas of medicine (eg, cardiology, radiology, and neurology). Currently, the field of psychiatry does not recognize interventionalists or offer formal training and certification. Our group is proposing the concept of “interventional psychiatrist” in place of procedure-specific terms such as “somatic therapist” or “ECT (electroconvulsive therapy) practitioner,” which fail to encompass the scope of brain stimulation strategies. It is not meant to replace current psychiatric therapies (medication and psychotherapy) but rather to enhance the practice of psychiatry with an additional set of tools. This can be viewed much in the same way that interventional cardiologists do not replace general cardiologists.

Dr. Kantor: I also see this bringing great opportunity for collaboration across neurology, neurosurgery, and psychiatry, which rarely occurs in other settings. This alone may advance our liaison activities and communication and, more than anything else, will facilitate better care between the disciplines and really help focus us on the whole person — mind, body, and brain — as opposed to one at a time, in isolation.

Medscape: How do you recommend that interventional psychiatry be incorporated into clinical training?

Dr. Kantor: It’s an emerging area of our field, where older techniques like ECT are being adapted for better efficacy with fewer side effects, and new techniques are coming of age. It’s not currently accredited on the training side, but my guess is that as it formalizes over the next 2-3 years, that process will naturally evolve. As a residency director, I support an educational plan that outlines minimum competencies, experience, and oversight. We already have begun exploring the paradigm with the American Association of Directors of Psychiatric Residency Training (AADPRT) and relevant specialty societies. I think the education has to begin with programs like ours at Medical University of South Carolina (MUSC), where the resources are more established, there are enough cases and mentors, and we can train practitioners and research scientists within psychiatry, in a way best suited to work within the existing graduate medical education framework.

A component of basic understanding and clinical exposure in residency would likely be the minimum expectation. On top of that, an optional, more formal track, using senior elective time, would be fairly easy to plan for within the existing training structure. Currently, not all programs have the expertise, but I believe that there is a desire among those that do to collaborate with needed tools like shared guidelines, online and remote learning, and course-based experiences. That said, I imagine that there will never be a one-size-fits-all plan that works in every institution.

Dr. Williams: Psychiatry is rapidly changing. New methods for noninvasively and invasively stimulating the brain have powerful therapeutic potential, but they require background knowledge (eg, circuits, physics of electricity) that is foreign to most psychiatrists. Interventional psychiatry is an emerging subspecialty that needs to be formally recognized and developed at various levels of psychiatric training. Academic centers will have to adapt to ensure adequate training to those who will be providing these neuromodulatory interventions, in order to avoid mistakes of an earlier era and to make sure that psychiatrists are the ones to perform the procedures, rather than other specialists who are clinically unfamiliar with the psychiatric disease management. Establishing formal training programs will ensure that psychiatry is ready to meet the challenges of treatment-resistant psychiatric illness with a properly trained cohort of interventional psychiatrists. We have an interventional psychiatry fellowship program at MUSC, and there are a few others starting around the country.

Approaches to Neuromodulation

Medscape: Can you walk our readers through the primary types of neuromodulation techniques used in psychiatry currently, and also in which conditions they are used, both on- and off-label?

Dr. Williams: Yes.

Transcranial magnetic stimulation (TMS): There are currently 2 different TMS coils that have been approved by the US Food and Drug Administration (FDA) for the acute treatment of depressed patients who have failed to respond to at least 1 antidepressant medication. Interventional psychiatrists need to understand the fundamental principles behind TMS and demonstrate competency in the delivery and programming of TMS paradigms. A recent multisite, naturalistic, observational study of acute treatment outcomes in clinical practice[2] demonstrated greater than 50% efficacy in sicker populations using TMS.

ECT: ECT is an effective acute treatment for a wide array of neuropsychiatric diseases (eg, depression, mania, psychosis) and remains the single most effective therapy for treatment-resistant depression (TRD). Although ECT has been used for nearly a century, advances in the way that it is delivered have greatly reduced side effects. Shorter pulse widths and unilateral electrode configurations have been shown to diminish cognitive side effects. Interventional psychiatrists should receive comprehensive ECT training that addresses indications and contraindications, length and timing of treatment, pulse programming, and maintenance therapy.

Focal electrically administered seizure therapy (FEAST): A new type of ECT has been developed, called FEAST. This unidirectional electrical stimulation with a novel electrode placement and geometry has been proposed as a means to initiate seizures in the prefrontal cortex prior to secondary generalization, but it is still in the research phase.[3]

Vagus nerve stimulation (VNS): VNS was FDA approved in 1997 to treat epilepsy, and in 2005 it became the first invasive neuromodulation device approved by the FDA as a treatment for a psychiatric disorder (chronic TRD). Unfortunately, VNS was FDA approved prior to any Class 1 evidence of efficacy; thus, insurance companies have been reluctant to reimburse for the implant. Nevertheless, the effects of VNS appear to be remarkably durable. Interventional psychiatrists should be the lead contacts on VNS consults and programming for TRD.

Deep brain stimulation (DBS): DBS is typically used to manage movement disorders but is now being investigated as a therapy for a variety of neuropsychiatric conditions such as obsessive-compulsive disorder (OCD), Tourette syndrome [still in research phase], addiction [still in research phase], and TRD [still in research phase]. In 2009, the FDA granted a somewhat controversial humanitarian device exemption for use of DBS for treatment-resistant OCD. Interventional psychiatrists will play a critical role in developing the field of functional neurosurgery for psychiatric disorders. Pertinent skills include patient consultation, intraoperative assessment, postoperative programming, troubleshooting, and integrating device settings with medications (psychopharmacology). There has also been an explosion in psychiatric side effects of DBS used for neurologic conditions like Parkinson disease. The interventional psychiatrist should be adequately trained to troubleshoot these issues.

Transcranial direct-current stimulation (TDCS): This is a therapy that involves an energy source that delivers a constant weak (typically ≤ 1 mA) electrical current through scalp electrodes. This therapy is not grandfathered in by the FDA as a device currently in practice, although other, similar devices are. A recent study[4] from Brazil demonstrated that when combined with sertraline, there is a synergistic effect in treating depression. There are limited data currently, but it seems to have great promise and low cost.

Putting Neuromodulation Into Practice

Medscape: Can you expand on how these techniques might be incorporated into care in conjunction with psycho- and pharmacotherapy?

TMS: In the pivotal trials, the patients were not on any medications. In the real world, TMS is typically combined with medications and therapy. There are now studies looking at combining therapy with TMS for a synergistic effect.

ECT: There are medications that, when used alongside ECT (venlafaxine/nortriptyline) or after ECT (lithium), increase the chances of improvement and better cognitive outcomes.

DBS: Typically this intervention can eventually replace medications; many of the studies reduced/removed medications once the device was working. In many instances, DBS (particularly in depression) will allow for patients to better participate in therapies that they would not have been able to participate in before.

TDCS: The most efficacy that has been shown to date is in combination with sertraline. This will potentially be a role for TDCS in enhancing therapeutic efficacy.

Medscape: Tell us about the interventional psychiatry training program at MUSC and how you envision the program evolving and affecting care.

Dr. Williams: Drs. Mark George and Baron Short have developed a 1-year interventional psychiatry fellowship with the first fellow, Dr. Jon Snipes, finishing June 30, 2013. A second fellow, Dr. Suzanne Kerns, will begin in July 2013.

We feel that interventional psychiatry should be present at 3 levels: (1) a core curriculum of introductory knowledge and experience during psychiatry residency training for all psychiatrists; (2) a neuromodulation elective track during residency at some locations; and eventually (3) a formal interventional psychiatry fellowship that leads to an approved subspecialty certification process under the American Board of Medical Specialties (ABMS).

Base resident education: Psychiatry residents should have an introductory-level understanding of the brain circuits underlying behavior and how they can be modulated using invasive and noninvasive brain stimulation. This fundamental knowledge should improve the quality of patient management by ensuring that patients are aware of the full complement of available therapeutic interventions. Ideally, all psychiatric residents would have a core curriculum that includes brain stimulation consultation and observation of ECT and TMS.

Interventional psychiatry track: Psychiatry residents who have a specific interest in brain stimulation should have the option of pursuing a dedicated training track within their residency program. Under this proposal, interested residents would be required to manage ECT and TMS treatment cases, from initial consultation to acute therapy and maintenance treatments. Psychiatrists who are currently performing these duties could be grandfathered into this arrangement.

Interventional psychiatry fellowship: Psychiatrists who wish to pursue the most rigorous training program should have the option of pursuing a 1-year fellowship that includes focused training in all of the aforementioned techniques. This training would occur at institutions with robust neuromodulation programs in collaboration with neurology, neurosurgery, and neuroradiology. Fellowship trainees should receive hands-on exposure in established (ECT, TMS, DBS, VNS) and emerging (eg, TDCS) neuromodulatory technologies. Additionally, fellowship trainees should have experience with the tools used to measure the effects of neuromodulation, such as functional MRI and EEG.

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Mixed Reaction to FDA Approval of ADHD Brain-Wave Test.

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Reactions have been mixed regarding the recent approval by the USFood and Drug Administration (FDA) of the first brain-wave testing system for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents. The new system is based on electroencephalogram (EEG) technology.

As reported by Medscape Medical News, the FDA approved the noninvasive Neuropsychiatric EEG-Based Assessment Aid (NEBA) system in July as a conjunctive tool in diagnosing ADHD in individuals between the ages of 6 and 17 years.

“Diagnosing ADHD is a multistep process based on a complete medical and psychiatric exam,” said Christy Foreman, director of the Office of Device Evaluation at the FDA’s Center for Devices and Radiological Health, in a release.

Used along with these important steps, the new system “may help healthcare providers more accurately determine if ADHD is the cause of a behavioral problem,” she added.

However, R. Scott Benson, MD, a child and adolescent psychiatrist in Pensacola, Florida, questions whether the new system really is any better than the diagnostic tools already in place — and whether it adds unnecessary costs.

“We live in a very cost-sensitive environment when it comes to healthcare,” Dr. Benson, who is also a member of the Council on Communications for the American Psychiatric Association, toldMedscape Medical News.

“As doctors, we love science and would love to find a definitive test to tell exactly what condition someone has. But we haven’t found that yet, and I don’t think this test is going in the right direction,” he added.

Nevertheless, Howard Merry, president of the device manufacturer (NEBA Health, LLC), stands by his product.

“While NEBA does cost patients up front, we believe the boost in clinician diagnostic accuracy will ultimately be cost saving,” he told Medscape Medical News.

Reliability Unclear?

The NEBA system, the use of which reportedly takes 15 to 20 minutes, calculates ratios of theta and beta brain waves given off each second. Past research has shown that this ratio is significantly higher in individuals with ADHD.

“ADHD is a very heterogeneous disorder. Our goal is to be more specific in defining these heterogeneous categories so that we can improve treatment,” Martin J. Drell, MD, president of the American Academy of Child and Adolescent Psychiatry (AACAP), told Medscape Medical News.

“Having such a system would be a dream come true, but I don’t think we’re there yet,” said Dr. Drell.

This was echoed in several of the many comments left by clinicians on Medscape Medical News’ Web site. Top concerns included cost and reimbursement issues, how sensitive and specific the testing system actually is, and that more research is needed.

On the other hand, some respondents called this a “big step” forward and noted that clinicians have in the past had to rely on parent-reported information or symptoms presented by the patient. Instead, this new system may eventually provide objective data.

“We are approaching the time of diagnosing diseases with tests,” as is the case in other branches of medicine, noted one commenter. “Still, it’s not clear the percentage of false positives, and the specificity and the reliability of the test,” he added.

Dr. Benson added that he was concerned that the approval appeared to be based on just 1 study, which was submitted by NEBA Health.

Study Details

Although full information on the study has not yet been publicly released, the FDA noted that 275 children and adolescents with attention or behavioral problems were evaluated. To determine whether the participants had ADHD, clinicians used the NEBA brain-wave testing system along with criteria from the fourth edition of theDiagnostic and Statistical Manual of Mental Disorders (DSM-IV), behavioral questionnaires and testing, and physical examinations.

“An independent group of ADHD experts reviewed these data and arrived at a consensus diagnosis regarding whether the research subject met critical criteria for ADHD or another condition,” reported the FDA.

Results showed that more accurate diagnoses of ADHD were found when the NEBA system was used along with clinical assessments than when clinical assessments alone were conducted.

A release by NEBA Health added that the “triple-blinded protocol showed only 61% agreement between individual clinicians and a multidisciplinary team.” However, that rate improved to 88% once the NEBA system was added.

“Our study supports that a clinician using NEBA as one part of a full ADHD evaluation would be more likely to converge upon diagnostic evaluation results of a multidisciplinary team,” said study chair Steve Snyder, MD, vice president of research and development at NEBA Health, in the release.

In addition to helping clinicians assess ADHD as a primary diagnosis, Dr. Snyder said that the system can help in determining whether the symptoms are actually caused by a different condition.

When asked for more details, the company president confirmed to Medscape Medical News that this was the same study listed on the ClinicalTrials.gov Web site that began in 2007 and ended in June 2008 at 13 sites in the United States. Although Lexicor Medical Technology is listed as the sponsor, NEBA Health acquired the assets of Lexicor in 2007.

Partial study results were presented at the 2011 International Congress on ADHD in Berlin, Germany, and at the 2010 Canadian ADHD Resource Alliance conference in Vancouver.

Merry reported that in more than 700 uses during the study and its follow-up, there were no adverse device events.

“EEG is extremely well characterized and is safe,” he said, adding that a paper discussing all of the results is in the process of being submitted to peer-reviewed journals.

When asked about costs, Merry reported that the NEBA equipment rents for $79 per month and that they charge patients approximately $325, depending on region.

“We collect our portion and the clinician’s portion of NEBA Services. The clinician is providing collection of EEG services, and we are providing digital analysis of EEG. CPT codes exist for both parts, and some third-party payers will reimburse when a correct ICD-9/10 code is applied,” he explained.

Debate Continues

Still, Dr. Benson is not yet convinced of the need for the device.

“Standard evaluation tools, including behavior rating scales, have been around for a long time. Those are still the gold standard, and I don’t believe this thing adds anything to the evaluation except for cost,” he said.

“The question is: does this really add anything to a good assessment? And it just doesn’t look to me like it is. If the case is that puzzling, it’s going to evolve over time. There’s nothing urgent about getting a diagnosis, and it isn’t an emergency room kind of thing,” said Dr. Benson.

“Clearly these children have been having problems for quite a while, and in a complicated case, it may take several visits to really understand what’s going on. But it’s okay to take that time,” he said.

He added that a problem in healthcare today is that “rather than adequately reimbursing a physician for taking time to do a good assessment, we want to suggest that there’s a test that’s going to provide the answer.”

“One of the biggest concerns I hear from parents is the idea of having children on medicine. And I don’t think this test is going to answer that for them at all. That’s only going to come from careful discussions with their physician.”

When asked about these issues, Merry answered that the new device “is not trying to take the place of the gold standard.” Instead, a clinician should perform a standard assessment prior to using the NEBA system.

“ADHD shares symptoms with many other psychiatric disorders. NEBA can be applied to patients who present with these attention and behavioral problems. After a standard clinical workup, the system can move that clinician’s diagnostic output closer to what a multidisciplinary team’s would be,” he said.

“It’s not replacing the gold standard; it’s integrating with the gold standard.”

Potentially Valuable

When asked for comment, Sandra Sexson, MD, professor of psychiatry and pediatrics and chief and training director of the Division of Child, Adolescent and Family Psychiatry at Georgia Regents University in Augusta, was cautiously optimistic.

“Sometimes parents need the confirming laboratory test when the diagnosis of ADHD is not too clear,” Dr. Sexson told Medscape Medical News. However, she noted that in many other cases, the diagnosis is clear and additional testing is not needed.

Still, Dr. Sexson, who also currently chairs the AACAP Work Group on Lifelong Learning, noted that the system could potentially play an important role.

“If the EEG can be used to differentiate ADHD from bipolar disorder, research that can be done now that the technique is approved to diagnose ADHD, such differentiation would be tremendously valuable to the practicing child and adolescent psychiatrist,” she said.

“It is fairly frequent that we struggle with that differentiation, particularly in younger youth.”

Source: Medscape.com

 

Are Doctors Diagnosing Too Many Kids with ADHD?

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A German children’s book from 1845 by Heinrich Hoffman featured “Fidgety Philip,” a boy who was so restless he would writhe and tilt wildly in his chair at the dinner table. Once, using the tablecloth as an anchor, he dragged all the dishes onto the floor. Yet it was not until 1902 that a British pediatrician, George Frederic Still, described what we now recognize as attention-deficit hyperactivity disorder (ADHD). Since Still’s day, the disorder has gone by a host of names, including organic drivenness, hyperkinetic syndrome, attention-deficit disorder and now ADHD.

Despite this lengthy history, the diagnosis and treatment of ADHD in today’s children could hardly be more controversial. On his television show in 2004, Phil McGraw (“Dr. Phil”) opined that ADHD is “so overdiagnosed,” and a survey in 2005 by psychologists Jill Norvilitis of the University at Buffalo, S.U.N.Y., and Ping Fang of Capitol Normal University in Beijing revealed that in the U.S., 82 percent of teachers and 68 percent of undergraduates agreed that “ADHD is overdiagnosed today.” According to many critics, such overdiagnosis raises the specter of medicalizing largely normal behavior and relying too heavily on pills rather than skills—such as teaching children better ways of coping with stress.

Yet although data point to at least some overdiagnosis, at least in boys, the extent of this problem is unclear. In fact, the evidence, with notable exceptions, appears to be stronger for the undertreatment than overtreatment of ADHD.

Medicalizing Normality

The American Psychiatric Association’s diagnostic manual of the past 19 years, theDSM-IV, outlines three sets of indicators for ADHD: inattention (a child is easily distracted), hyperactivity (he or she may fidget a lot, for example), and impulsivity (the child may blurt out answers too quickly). A child must display at least six of the nine listed symptoms for at least half a year across these categories. In addition, at least some problems must be present before the age of seven and produce impairment in at least two different settings, such as school or home. Studies suggest that about 5 percent of school-age children have ADHD; the disorder is diagnosed in about three times as many boys as girls.

Many scholars have alleged that ADHD is massively overdiagnosed, reflecting a “medicalization” of largely normative childhood difficulties, such as jitteriness, boredom and impatience. Nevertheless, it makes little sense to refer to the overdiagnosis of ADHD unless there is an objective cutoff score for its presence. Data suggest, however, that a bright dividing line does not exist. In a study published in 2011 psychologists David Marcus, now at Washington State University, and Tammy Barry of the University of Southern Mississippi measured ADHD symptoms in a large sample of third graders. Their analyses demonstrated that ADHD differs in degree, not in kind, from normality.

Yet many well-recognized medical conditions, such as hypertension and type 2 diabetes, are also extremes on a continuum that stretches across the population. Hence, the more relevant question is whether doctors are routinely diagnosing kids with ADHD who do not meet the levels of symptoms specified by the DSM-IV.

Some studies hint that such misdiagnosis does occur, although its magnitude is unclear. In 1993 Albert Cotugno, a practicing psychologist in Massachusetts, reported that only 22 percent of 92 children referred to an ADHD clinic actually met criteria for ADHD following an evaluation, indicating that many children referred for treatment do not have the disorder as formally defined. Nevertheless, these results are not conclusive, because it is unknown how many of the youth received an official diagnosis, and the sample came from only one clinic.

Clearer, but less dramatic, evidence for overdiagnosis comes from a 2012 study in which psychologist Katrin Bruchmüller of the University of Basel and her colleagues found that when given hypothetical vignettes of children who fell short of the DSM-IVdiagnosis, about 17 percent of the 1,000 mental health professionals surveyed mistakenly diagnosed the kids with ADHD. These errors were especially frequent for boys, perhaps because boys more often fit clinicians’ stereotypes of ADHD children. (In contrast, some researchers conjecture that ADHD is underdiagnosed in girls, who often have subtler symptoms, such as daydreaming and spaciness.)

Pill Pushers?

Published reports of using stimulants for ADHD date to 1938. But in 1944 chemist Leandro Panizzon, working for Ciba, the predecessor of Novartis, synthesized a stimulant drug that he named in honor of his wife, Marguerite, whose nickname was Rita. Ritalin (methylphenidate) and other stimulants, such as Adderall, Concerta and Vyvanse, are now standard treatments; Strattera, a nonstimulant, is also widely used. About 80 percent of children diagnosed with ADHD display improvements in attention and impulse control while on the drugs but not after their effects wear off. Still, stimulants sometimes have side effects, such as insomnia, mild weight loss and a slight stunting of height. Behavioral treatments, which reward children for remaining seated, maintaining attention or engaging in other appropriate activities, are also effective in many cases.

Many media sources report that stimulants have been widely prescribed for children without ADHD. As Dutch pharmacologist Willemijn Meijer of PHARMO Institute in Utrecht and his colleagues observed in a 2009 review, stimulant prescriptions for children in the U.S. rose from 2.8 to 4.4 percent between 2000 and 2005. Yet most data suggest that ADHD is undertreated, at least if one assumes that children with this diagnosis should receive stimulants. Psychiatrist Peter Jensen, then at Columbia University, noted in a 2000 article that data from the mid-1990s demonstrated that although about three million children in the U.S. met criteria for ADHD, only two million received a stimulant prescription from a doctor.

The perception that stimulants are overprescribed and overused probably has a kernel of truth, however. Data collected in 1999 by psychologist Gretchen LeFever, then at Eastern Virginia Medical School, point to geographical pockets of overprescription. In southern Virginia, 8 to 10 percent of children in the second through fifth grades received stimulant treatment compared with the 5 percent of children in that region who would be expected to meet criteria for ADHD. Moreover, increasing numbers of individuals with few or no attentional problems—such as college students trying to stay awake and alert to study—are using stimulants, according to ongoing studies. Although the long-term harms of such stimulants among students are unclear, they carry a risk of addiction.

A Peek at the Future

The new edition of the diagnostic manual, DSM-5 (due out in May), is expected to specify a lower proportion of total symptoms for an ADHD diagnosis than its predecessor and to increase the age of onset to 12 years. In a commentary in 2012 psychologist Laura Batstra of the University of Groningen in the Netherlands and psychiatrist Allen Frances of Duke University expressed concerns that these modifications will result in erroneous increases in ADHD diagnoses. Whether or not their forecast is correct, this next chapter of ADHD diagnosis will almost surely usher in a new flurry of controversy regarding the classification and treatment of the disorder.

 

Source: Scientific American

 

Internet Addiction is the New Mental Health Disorder.

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The next edition of the Diagnostic and Statistical Manual for Mental Disorders(DSM) – often referred to as the ‘s (APA) diagnostic “bible” – is due out in May 2013.

In this latest edition, DSM-5, “Internet use disorder” will be recommended as an area that needs further study.

While you won’t be able to be diagnosed with Internet use disorder just yet, recommending it for further study puts it squarely on the psychiatric radar, which means it’s likely to be bumped up to an actual mental health disorder very soon.

What is Internet Use Disorder?

As defined by the APA, Internet use disorder includes many characteristics of anyaddiction, such as experiencing withdrawal symptoms when the object of addiction is taken away, an inability to control its use, developing a tolerance to it, deceiving family members about its use, and losing interests in other hobbies. In this case, of course, the object of abuse is the Internet.

According to the APA, you might have a problem if you display these symptoms:1

Preoccupation with Internet gaming Withdrawal symptoms when Internet is taken away Tolerance: the need to spend increasing amounts of time engaged in Internet gaming
Unsuccessful attempts to control Internet gaming use Continued excessive Internet use despite knowledge of negative psychosocial problems Loss of interests, previous hobbies, entertainment as a result of, and with the exception of Internet gaming use
Use of the Internet gaming to escape or relieve a dysphoric mood Has deceived family members, therapists, or others regarding the amount of Internet gaming Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of Internet gaming use

 

Certainly, some may have a legitimate problem with spending too much time online, in the same way that people become addicted to gambling, television, pornography… the list is endless. It’s quite possible to become addicted to virtually anything if it is used to the point where it interferes with other aspects of your life and puts your health, financial stability or relationships at risk…

But by making Internet addiction a certifiable mental illness, it then becomes treatable by drugs and billable through insurance companies – and morphs into a “disorder” that is likely something that will stigmatize your health records for the rest of your life. Not to mention, over-treatment is a very real risk… as has occurred with depression, ADHD, insomnia, and countless other conditions, many people with only “mild” cases may be diagnosed, and given drugs, when they are not at all necessary.

It is often the case that the newest mental health disorders are also those that happen to create the largest new drug markets. Millions of Americans, including me, use the Internet on a daily basis, many for hours on end, so the potential treatment market for “Internet use disorder” is huge.

Grief: Another “Disorder” Being Added to DSM-5

Grief is a highly individual experience, but for most people it takes two to six months to “run its course” – and sometimes much longer, all of which is normal and to be expected in the face of a significant loss. But according to DSM-5, you may actually have an “Adjustment Disorder” related to bereavement if:2

“Following the death of a close family member or close friend, the individual experiences on more days than not intense yearning or longing for the deceased, intense sorrow and emotional pain, or preoccupation with the deceased or the circumstances of the death for at least 12 months (or 6 months for children). The person may also display difficulty accepting the death, intense anger over the loss, a diminished sense of self, a feeling that life is empty, or difficulty planning for the future or engaging in activities or relationships.”

These all sound like normal reactions following the death of a loved one, but the DSM-5 also proposes further study for Persistent Complex Bereavement Disorder, with the purpose being to “develop the best empirically-based set of symptoms to characterize individuals with bereavement-related disorders.”

Close to 2.5 million Americans die each year, and the number of those experiencing grief as a result is far higher. This is the market the pharmaceutical industry stands to gain, thanks to the APA’s trigger-happy attitude when it comes to labeling normal human emotions as psychiatric “disorders.”

Who Really Needs Their Heads Examined?

The APA works in tandem with the drug industry, “creating” more and more “psychiatric diseases,” which are appearing in the literature all the time:

  • Do you shop too much? You might have Compulsive Shopping Disorder.
  • Do you have a difficult time with multiplication? You could be suffering from Dyscalculia.
  • Spending too much time at the gym? You’d better see someone for your Bigorexia or Muscle Dysmorphia.
  • And my favorite – are your terrified by the number 13? You could have Triskaidekaphobia!

Each of these new “diseases” gets added to the next edition of the DSM if enough people show up with those traits. And increasingly, the criteria for inclusion involves whether or not the disorder responds to a category of drugs. If it does, the phenomenon is dubbed a disease.

Of the 297 mental disorders described in the DSM, none can be objectively measured by empirical test.3 In other words, they’re completely subjective! Mental illness symptoms within this manual are arbitrarily assigned by a subjective voting system by a psychiatric panel. So, they’re essentially making up diseases to fit the drugs – not the other way around.

According to marketing professional Vince Parry in a commentary called “The Art of Branding a Condition“:4

“‘Watching the Diagnostic and Statistical Manual of Mental Disorders (DSM) balloon in size over the decades to its current phonebook dimensions would have us believe that the world is a more unstable place today than ever.’ …Not surprisingly, many of these newly coined conditions were brought to light through direct funding by pharmaceutical companies, in research, in publicity or both.”

A former chief of the American Psychiatric Association even admitted that some of the “mistakes” the APA made in its diagnostic manual have had “terrible consequences,” which have mislabeled millions of children and adults, and facilitated epidemics of mental illness that don’t exist.5

It’s almost impossible to see a psychiatrist today without being diagnosed with a mental disorder because so many behavior variations are described as pathology. And you have very high chance – approaching 100% – of emerging from your psychiatrist’s office with a prescription in hand. Writing a prescription is, of course, much faster than engaging in behavioral or lifestyle strategies, but it’s also a far more lucrative approach for the conventional model. Additionally, most practitioners have yet to accept the far more effective energetic psychological approaches, like the Emotional Freedom Technique (EFT).

Do You Suspect You’re Spending Too Much Time Online?

Getting back to the topic of Internet addiction, it’s quite possible to overdo your time spent online. But psychotropic drugs are not likely to give you the solution you’re after. For starters, they have no known measurable biological imbalances to correct – unlike other drugs that can measurably alter levels of blood sugar, cholesterol and so on.

How can you medicate something that is not physically there? The answer is, of course, you can’t – and doing so is a dangerous game. In other words, drugs are probably not the answer to solving your Internet addiction.

What, then, is?

First of all, I want to point out that it absolutely is detrimental to your physical and emotional health to spend too much time in front of a computer. For one thing, it’s way too much sitting. “Screen time” – more than two hours a day in particular – is associated with increased physical, emotional and behavioral difficulties, regardless of the time spent exercising. Research has shown:

  • A study of more than 17,000 Canadians found that the mortality risk from all causes was 1.54 times higher among people who spent most of their day sitting compared to those who sat infrequently.6
  • Sitting time is a predictor of weight gain, even after accounting for calories consumed and leisure time physical activity, such as exercise time.7
  • The risk of metabolic syndrome rises in a dose-dependent manner depending on your “screen time” (the amount of time you spend watching TV or using a computer). Physical activity had only a minimal impact on the relationship between screen time and metabolic syndrome.8
  • Children who spent more than two hours a day watching TV or using a computer were 61 and 59 percent more likely to experience high levels of psychological difficulties, respectively.9

If online gaming or gambling is involved, the problem could seriously escalate, as well as if you’re neglecting your other responsibilities in order to participate in online gaming or other online activities.

If you suspect you have a problem, I suggest giving EFT a try. EFT is a form of psychological acupressure, based on the same energy meridians used in traditional acupuncture to treat physical and emotional ailments for over 5,000 years, but without the invasiveness of needles. Instead, simple tapping with the fingertips is used to input kinetic energy onto specific meridians on the head and chest while you think about your specific problem – whether it is a traumatic event, an addiction, pain, etc. – and voice positive affirmations.

This combination of tapping the energy meridians and voicing positive affirmation works to clear the “short-circuit” – the emotional block – from your body’s bioenergy system, thus restoring your mind and body’s balance, which is essential for optimal health and the healing of physical and emotional disease.

Source: Dr. Mercola