Face It: You're Crazy (But So Is Everyone Else)

Flickr/Mark Turnauckas

Commonly referred to as "the DSM," the Diagnostic and Statistical Manual of Mental Disorders is often referred to as psychiatry's "Bible." If that's the case, imagine the outcry if an overzealous publisher merged the Gospels of Luke and Mark, and you have a pretty good idea of the controversy surrounding the release of the manual's fifth edition.

After a six-year revision process—and nearly 20 years since the last edition—the American Psychiatric Association (APA) released the DSM-5 at its annual meeting this weekend, the product of 13 working groups and input from more than 1,500 professionals. Any effort to draw a line between the normal and the abnormal is sure to ignite debate, and it's no surprise that doctors and patients who rely on official diagnoses for health-insurance coverage have scrutinized the new DSM's every word. Among the most controversial changes: Grief following a loved one's death is now classified as a form of major depression; forgetfulness in old age as "minor neurocognitive disorder"; and worrying about your medical condition as "somatic symptom disorder." Asperger's is being folded into the autism spectrum. While the new edition contains approximately the same number of mental disorders as the previous one, the 992-page manual broadens the criteria for many ailments, making it easier to obtain a diagnosis. Critics say this will classify the "worried well" as mentally ill and turn us into a Prozac Nation of dead-eyed pill poppers. The new DSM, in other words, pathologizes normal and plays into the hands of money-hungry pharmaceutical companies.

Despite cries about an oncoming Huxleyan dystopia, the more lax DSM is a good thing: Broadening of definitions of mental disorders—and yes, diagnosing more people with one—will go a long way in erasing the dirty signifiers that come part and parcel with mental illness. The uproar over the DSM-5 only shows the stock we continue to put in labels like "major depression," "OCD," and "ADHD”—and the degree to which being diagnosed with a mental disorder still carries a stigma. Would reclassifying types of skin disease cause such a stir?

Among the DSM-5's most vocal critics has been Allen Frances, professor emeritus at Duke University and the lead researcher behind the previous edition of the manual. "[The DSM-5] will start a half or dozen or more new fads which will be detrimental to the misdiagnosed individuals and costly to our society," Frances said shortly before the manual's release. “Pretty soon, everyone’s going to have a mental disorder or two or three,” he told Mother Jones

This is a common view, but there is no proof that Americans are overdiagnosed or overmedicated. Sure, antidepressant use has skyrocketed 400 percent since 1988; an estimated 11 percent of Americans now take drugs to treat depression. It's also true that the rate of ADD has tripled in the past 15 years; 4 percent of kids now take medication for the disorder. But this doesn’t necessarily mean people are being overdiagnosed. The fact is, mental illness is far more common than most people think.

Under the guidelines of the previous DSM-IV edition, one in five of Americans would currently qualify as having a mental illness, and half would at some point in their lifetimes. While there are certainly doctors who may rush to medicate patients as a quick fix for routine anxiety or run-of-the-mill childhood misbehavior—pharmaceutical companies certainly have a financial interest in encouraging this kind of care—the primary problem with mental illness in the United States is undertreatment. Fewer than half of those who suffer from mental illness seek treatment; it’s out of reach for a great number of Americans. This is particularly the case for racial and ethnic minorities, who suffer from mental illness at rates comparable to the rest of population but are underserved by the mental-health community. For example, only one in 20 Hispanics who experience mental illness seek professional care, African Americans are 20 percent more likely than non-Hispanic whites to report serious psychological distress, and Asian-American women have the highest suicide rate of all women over 65.

Critics accuse DSM-5 of relying too heavily on self-reports from patients and the subjective assessments of psychiatrists as well. Unlike most of medicine, psychiatric diagnoses are not rooted in biology. This was essentially the criticism of the National Institute of Mental Health—one of 27 institutes and centers that make up the National Institutes of Health—which condemned the DSM-5 in a statement: "Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure." But as Kenneth Zucker, the chair of one of the DSM working group points out, "The data are the data. That's where the field is at." The science of the mind simply has not advanced to the point where diagnosing autism is like testing for diabetes—and given how complex and multifaceted human cognition is, it's unlikely it will ever be that straightforward.

But is that such a bad thing? While it's comforting to think the line between crazy and sane is clear—and that you're on the right side of it—the real difference between being feeling depressed and "Depression" is whether one steps into a doctor's office to get assessed and treated. It's up to the patient to decide whether his or her problem is severe enough to seek relief. This is perhaps the best way to think of the new DSM: Not as the definitive map of the human psyche, but as a flawed tool for guiding doctors to fix what ails us.

Comments

As a clinical social worker, I've been thoroughly disgusted with the press coverage of the DSM-5. It's mostly just been a bunch of scare-mongering to generate web hits. Even the couple of positive articles I've read, such as this one, have been weak. I'll give this writer a pass on the title, since he probably didn't write it, but it doesn't take long for him to come up with a doozy: "Grief following a loved one's death is now classified as a form of major depression." This is simply not true. The change in the DSM-5 is that a person CAN be diagnosed with depression while they are grieving. The previous DSM forbade this. But grief is NOT being classified as a form of depression. It's actually the opposite: If a person is experiencing normal grief, they do not meet criteria for depression. They would only meet critieria for depression if their symptoms go well beyond what would be expected in a grieving person. I would agree that this change opens up the possibility for overdiagnosis of depression, but it's hard to have a reasonable debate when nobody, including Dr. Allen Frances (I've read his articles), seems interested in presenting the facts accurately.

I do give this writer credit for acknowledging that mental illness cannot be definitively diagnosed in the way that many medical illnesses can. Many people seem to think that things that are not 100% provable can be safely ignored, an idea that may sound fine in theory but is unworkable in the real world. I would also add that there are, in fact, many medical diagnoses that are ultimately judgment calls on the part of the physician. What mental illnesses really are is syndromes. Maladaptive behaviors frequently occur in patterns, and recognizing these patterns (i.e., making a diagnosis) can be helpful in determining what kinds of treatment may be most effective. But any good clinician can tell you that diagnosis is only one piece of the puzzle, as everyone is different and treatment must be tailored to the individual.

Last summer I served on a jury for a tobacco trial, and spent 3 weeks listening to several expert witnesses MD's testify about tobacco, including the DSM, specifically concerning the topic of nicotine addiction. One, while insisting he did not use the DSM as "cook book" to diagnose patients, then went on to explain how he used the DSM essentially as a cook book to diagnose patients. All the expert witnesses were loath to define the term "addiction". As an ex-smoker myself who quit cold turkey, it was quite the education.

Since the trial was about whether the plaintiff was addicted to smoking or not, much time was spent on throwing water on the idea that nicotine is an addictive substance, since smokers "quit all the time". Big Tobacco was happy to admit that tobacco causes cancer and kills, but they are not about to own that it's addictive.

It became apparent in the historical review of the tobacco industry how much influence it has had on medicine, including the revision of DSM-5. It now seems to relieve Big Tobacco of any liability for addictive properties of nicotine since DSM-5 newly requires addiction to be caused by an "illicit" substance, and as we all know, tobacco is perfectly legal.

That means it's not addictive! Who knew?

Kabuki perücke Stil verwendet ltiger, es gibt hundert Arten, von denen haben mehr als 60 Arten von Winkeln mit der Perücke, weibliche Perücke Ecke mit 40 Arten. Diese Perücken schweren schwersten rekonfigurierbare fünf Kilogramm leichter haben etwa 2 kg. Schauspieler eine Perücke einen Hut bevor er seinen Kopf in sie tragen. Die Verwendung von Perücken auf das Geschlecht des Charakters, Alter, Beruf usw., um festzustellen, basiert.

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