The ongoing revision of the Diagnostic and Statistical Manual of Mental Disorders has provoked prominent psychiatrists to declare that the next version (DSM-V) is in danger of medicalizing normality. Since “normality” covers quite a few people who don’t think of themselves as mentally disordered, I thought it would be important to look into this rather than keep pawing obsessively at the wrapping of my own little human package. There is a powerful social world out there, after all, and it has stamped me, for one, with a numerical code for major depression. That number may not be so ominous as one consigning me to prison, but it’s mine for life in the eyes of that world, no matter how fully recovered I might consider myself to be.
The debate about how the revision should be handled clarifies for me the evolution of the DSM and the effects of the present system. I’m interested primarily in getting a handle on the basic approach rather than following details of the major battles. (Go to the excellent Carlat Psychiatry Blog to stay current on the controversy.) The public exchanges among prominent psychiatrists reveal the darker side of current and potential methods for diagnosis and treatment.
A lengthy, footnoted editorial by Dr. Allen Frances, the former chairman of the DSM-IV revision committee, makes some telling points. He attacks the claim that DSM-V will mark a paradigm shift in diagnosis. (A response, however, by another distinguished psychiatrist argues that this is an exaggeration.)
Whatever the DSM-V revision group may or may not be claiming, Dr. Francis helps a lay person like me understand the basic nature of the DSM system of classification. He points out that the manual relies on descriptive diagnosis, meaning that it labels each set of symptoms as a given mental disorder but without, for the most part, any proven physical basis explaining its cause, or any scientific method of testing for the condition. He argues that there can’t be any great advance in a descriptive system until knowledge of the biology and neuroscience of the brain have advanced far beyond the current state.
Many of his criticisms echo the ones that have been made for years about his own handiwork – DSM-IV. Take, for example, the phrase from the title – “mental disorders.” Lacking knowledge of the specific physiological changes giving rise to symptoms, the editors of the DSM decided they couldn’t characterize the conditions they observed as “diseases” – like diabetes or cancer. So they came up with the word “disorder” to cover the conditions they identified. Unfortunately, that word has no precise meaning. According to DSM-IV itself: “…it must be admitted that no definition adequately specifies precise boundaries for the concept of mental disorder.” DSM-V may try to push those boundaries farther out and, in so doing, extend the psychiatric domain over millions of additional people.
For example, the DSM committees have been considering adding diagnostic categories for “subthreshhold” conditions that are milder forms of the existing disorders. As Dr. Frances puts it:
The reported rates of DSM-V mental disorders would skyrocket, especially since there are many more people at the boundary than those who present with the more severe and clearly “clinical” disorders. The result would be a wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatments – a bonanza for the pharmaceutical industry but at a huge cost to the new false positive “patients” caught in the excessively wide DSM-V net. They will pay a high price in side effects, dollars, and stigma, not to mention the unpredictable impact on insurability, disability, and forensics.
(Of course, DSM-IV did quite well at achieving the same result but evidently left a lot of room for growth.) Even worse than the subthreshold disorders, though, is the idea of adding a “pre-psychotic” category. This would be used for anyone thought to be a high risk for later developing a psychotic disorder. What would you call later? A month, a year, 10 years, 20?
I can’t imagine the criteria for such a diagnosis, but I suppose it would hardly matter which vague symptoms would need to be observed or what the time projection might be. A psychiatrist would have a frightening power to stigmatize someone for life. There’s plenty of over-medication and involuntary confinement now, but this could trigger the use of such methods without the bother of having to wait for actual symptoms to occur.
Dr. Frances’ scenarios may be overdrawn, as defenders of the DSM-V process claim, but this debate brings out issues that predate the current battle and go to the heart of the impact of the DSM on all of us. Dr. Paul Chodoff, writing from his perspective as a practitioner with 50 years of experience at the time, entitled a 2002 editorial, The Medicalization of the Human Condition.
He points out that much of the “medicalization of normality” that alarms Dr. Frances was already a problem under DSM-IV. As he says, the vagueness of the definition of “mental disorders” created a gray area between pathology and normality. In that area fall many undesirable feelings and behaviors “that are not readily distinguishable from the range of experiences that are often inescapable aspects of the fate of being human.”
Extreme shyness, for example, has gradually been transformed from a personality trait to a medical condition. The screening criteria for major depression have created such a low threshold as to include many states that used to be considered part of the ups and downs of any life. These changes in definition, he argues, have caused the apparent skyrocketing of social phobia and depression. While DSM supporters claim that strict adherence to the prescribed diagnostic procedures would prevent such problems, Chodoff responds that subjective interpretation of checklists can’t get it right all the time.
He believes that the early application of DSM principles helped to lift psychiatry out of the days when psychoanalysis was the dominant model, and medical explanations were scorned. But now, he believes, medicalizing psychological conditions has gone too far. People suffering from what he calls “problems of living” should seek psychotherapy alone without medication. But that approach is rarely accepted by insurance companies. They seem to be much happier paying for drugs, despite the soaring costs and ever more common use.
What Chodoff urges (and it makes so much sense to me) is that psychiatry and the other helping professions need to accept the reality that their work “transcends” the medical model. It often deals with conditions that are not pathological but still cause a lot of suffering. People need help for many reasons, but they don’t always need medication.
The next post will look at a proposed alternative to the DSM diagnostic method that goes beyond changing psychiatric practice to changing how we think of our own lives.
What’s your experience with the results of the DSM approach? These days it’s quite common to get multiple diagnoses for each aspect of what troubles us. Has that been helpful to you or has it set you back?