Behaving badly has disorder to call its own

Ever-growing list of mental illnesses met by skepticism

Much of the controversy surrounded personality disorders and mental illness among children. Among the most recently defined mental ailments, several drew particular scorn: mathematics disorder, reading disorder and disorder of written expression.

Based on definitions in the DSM-IV, naughty children can be diagnosed with oppositional defiant disorder and cigarette smokers with nicotine dependence. "If You're Breathing, You're In The Book," a 1994 newspaper headline in the Greensboro, N.C., News & Record declared. Another newspaper asked, "Is it True? Are We All Crazy?"

More recently, doctors have begun suggesting disorders that should be included in the next revision of the manual, due in 2011.

Caplan said one doctor is proposing a new diagnosis, relational disorder, which she summarizes as a dysfunctional relationship in which "neither person is mentally ill but the relationship is."

She said she wonders what would happen when an afflicted couple visits the doctor's office for help. "The psychiatrist takes out a pill. ... Where does the psychiatrist put it?" she asked. Other doctors have suggested broadening the definition of bipolar disorder, an illness once known as manic depression, characterized by extreme mood swings from elation to deep despair.

Under the proposed changes in the DSM, "everyone who's had any kind of mood swings in their life becomes bipolar," Torrey said. "And because of that, the concept loses meaning."

While the APA's Narrow agrees the jury is out on expanding the definition of bipolar disorder - particularly when it would enrich the drug manufacturers whose medicines are used to treat it - he argues that refining the definition of old disorders and identifying new ones is important. "It means patients are more likely to get better treatment for their disorders," he said. "An accurate diagnosis leads to an accurate treatment."

The findings of the IED study released in June support that view, according to Ronald C. Kessler, the Harvard scientist who led the research team. The researchers found that IED often appears in adolescence but is later compounded by other problems such as alcoholism and depression. Identifying and treating the anger attacks early on might help prevent the problems that boil up, he said.

The study found that over a lifetime, people with IED averaged 43 rage attacks resulting in $1,359 in property damage. "The question is, can you make them into regular people, and there is evidence we can," Kessler said.

Part of the reason for public skepticism about psychological disorders is a long-standing stigma surrounding mental illness, said Bob Corolla, a spokesman for the National Alliance for the Mentally Ill.

"There are still people who believe mental illnesses are a function of character and not illness," he said. "If you interview Tom Cruise, he might tell you that."

The movie star is a member of the Church of Scientology, which eschews psychiatric treatment, and he publicly criticized actress Brooke Shields in 2005 for taking medication for postpartum depression.

Corolla said he first learned of IED from a short-lived Fox comedy called Head Cases, in which one character, a lawyer, had the disorder.

"In a trial, he hit the other attorney in the head with a law book, and I wondered if it was even a disorder," Corolla said.

A scientist with the alliance later confirmed to him that IED was legitimate. In fact, researchers have found that the propensity for angry outbursts might be inherited - and regarded as a kind of epilepsy.

"We are not as concerned about what they call it," Corolla said. "Take the name away, you're still dealing with a set of symptoms that need treatment."

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Disorders of note

Here are some disorders officially identified by the American Psychiatric Association and a few symptoms of each.

Narcissistic personality disorder: Grandiose sense of self-importance; arrogant or haughty behaviors; believes that he or she is "special"; sense of entitlement.

Disorder of written expression: Writing skills that are substantially below those expected, given the person's chronological age, measured intelligence and age-appropriate education.

Factious disorder: Intentional production or feigning of physical or psychological signs or symptoms but for no apparent reason.

Nightmare disorder: Extended and extremely frightening dreams, usually involving threats to survival, security or self-esteem.

Avoidant personality disorder: Reluctance to take personal risks or to engage in any new activities because they may prove embarrassing.

Antisocial personality disorder: Failure to conform to social norms; deceitfulness; irritability; lack of remorse.

Conduct disorder: Physically cruelty to people and animals; staying out at night despite parental prohibitions, beginning before age 13; lying to obtain goods or favors or to avoid obligations.

General anxiety disorder: Excessive anxiety and worry, occurring for at least 6 months, about a number of events or activities; muscle tension; difficulty concentrating or mind going blank.[Source: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition]