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Does very severe PMS constitute a mental disorder? That's one of many questions facing psychiatrists as they work to revise the Diagnostic and Statistical Manual of Mental Disorders or DSM, the definitive compendium of our psychic maladies. Because the DSM influences not just doctors and patients but medical research, insurance companies, the pharmaceutical industry, advertising and the culture at large, controversy surrounding its new edition abounds. Brooke looks at this powerful book.
BROOKE GLADSTONE: There’s a saying that goes, “A good book is the best of friends, the same today and forever.” But books that are periodically revised can be even better. Consider the Diagnostic and Statistical Manual of Mental Disorders, or DSM, the catalog of mind-based maladies designated by the American Psychiatric Association.
Plagued by fears or fantasies, bad thoughts or bad behaviors? If the problem’s in your head, it’s in the DSM, charting your psychic pain since 1952.
The next edition, the fifth in 60 years, isn't due out until 2012, but now’s the time when new disorders are debated, tested and prepped for their debuts in the
DSM-V. The world consults this book. This is a very big deal -
DR. DARREL REGIER: - because the disorder definitions that we provide are used by the FDA to determine whether or not new medication might have an indication for treatment.
BROOKE GLADSTONE: Dr. Darrel Regier is the vice-chair of the DSM-V Task Force.
DR. DARREL REGIER: It’s used by the NIH to assess the type of disorder that somebody is asking to research. It’s also used by Medicare, Medicaid and insurance companies to identify the condition that somebody is requesting payment of treatment for.
BROOKE GLADSTONE: Most important, it’s used by doctors to define what’s normal and what’s not. It was the DSM that officially declared homosexuality a mental disorder, and then in 1973 officially undeclared it.
It’s defined an ever-expanding range of phobias and addictions that we're still arguing about, but this time, demands for more transparency aim to crack open the window on DSM-V deliberations so interested parties can weigh in before they are enshrined – because once they are, the FDA approves drugs to treat them, and any further debate is drowned out in the flood of direct-to-consumer ads.
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WOMAN: If you are one of the many who suffer from overwhelming anxiety and intense fear of social situations with unfamiliar people -
MAN: You know when you’re not feeling like yourself. You’re tired all the time. You may feel sad, hopeless, and lose interest in things you once loved. You may feel anxious.
WOMAN: You can feel it in so many ways. Cymbalta can help. Cymbalta is a prescription medication that treats many symptoms of depression.
BROOKE GLADSTONE: One controversial diagnosis up for inclusion is gender identity disorder. For social conservatives and some religious groups, this is a definite thumbs-up for inclusion in the DSM. If you think you’re a woman trapped in a man’s body or vice versa, you have a disorder.
But Dr. Michael First, who worked on the last two editions of the DSM, says that for those in the transgender community it’s not so simple.
DR. MICHAEL FIRST: People who want sex reassignment surgery, who are transgendered so much so that they feel like they have to go all the way and actually change their gender - they need to view this as a disorder in order to qualify for the surgery.
BROOKE GLADSTONE: You mean to get insurance to cover it.
DR. MICHAEL FIRST: Insurance, and also social acceptance. The people who are against it are people who see being transgendered as a lifestyle choice and part of the normal variation, and they just see the stigma.
BROOKE GLADSTONE: Similarly, feminists stand on both sides of the debate over a form of PMS affecting five percent of menstruating women that is so severe it impairs their ability to function. It’s called PMDD, or -
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WOMAN: Premenstrual dysphoric disorder, a distinct medical condition. It causes intense mood and physical symptoms right before your period. Doctors can now treat PMDD with Sarafem, the first and only prescription medication for PMDD.
STEF PROSE: When the Sarafem commercials came out was when I got, you know, the ah-ha!
BROOKE GLADSTONE: Stef Prose was being treated for depression, even though she rejected that diagnosis and felt stigmatized by it. When she saw the Sarafem ad depicting her debilitating mood swings, her rages and her guilt, she finally felt she had a real diagnosis and was deeply relieved and grateful.
STEF PROSE: Somebody knows actually what I'm talking about. And immediately I called my doctor and said, this is what I have. I want depression [LAUGHS] taken off the record.
BROOKE GLADSTONE: Like so much in the DSM, diagnosis is a judgment call, but Stef Prose, who now blogs about PMDD at Lifewpmdd.com, has no trouble passing judgment on whether it should be in the DSM.
STEF PROSE: My answer is yes. Trying to go to work every day and getting the energy to do it, it does, it affects you every single day. And to me, that is a disorder.
BROOKE GLADSTONE: PMDD has languished in the appendix of the DSM, signifying that the jury is still out. It is a hot-button issue because, you know, this one’s just for the ladies, and it could be used against them – all of them.
But the political ramifications don't worry Stef Prose.
STEF PROSE: I hadn't really thought about it. I guess the way I look at it is, it is kind of a sexist disease. [LAUGHS]
BROOKE GLADSTONE: Sarafem, just Prozac in pink, is still available, but the FDA demanded that Eli Lilly pull the ads because they described the symptoms of PMDD so broadly they were virtually indistinguishable from what most women experience as PMS, a condition not currently up for inclusion in the DSM.
DR. JONATHAN METZL: If we are in the business of treating PMS with psychiatric drugs, in part what we're saying is that there is a level of insanity to the suffering of [LAUGHS] PMS.
BROOKE GLADSTONE: Jonathan Metzl, psychiatrist and author of Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs.
DR. JONATHAN METZL: Historically speaking, psychiatric drugs have been used to convey the message that if you’re not just suffering from an illness but if you’re not a good mother, if you are not a good wife, these are all conditions that can be treated with psychiatric medications.
And I can say that historically the blurriness of that line has gotten psychiatry into a lot of trouble. The “mother’s little helper” phenomenon in the '70s is one example of that.
BROOKE GLADSTONE: Valium.
DR. JONATHAN METZL: Correct. We know that when the industry drives diagnosis, there’s a process that happens that Peter Kramer, in Listening to Prozac, beautifully described as “diagnostic bracket creep.” People start to come into doctor’s offices and say, I know this drug is indicated for a particular illness, but I've kind of got that. And the doctor says, that sounds good enough. We'll give you this medication.
And what happens over time is that the diagnostic boundaries expand and expand and expand so that a drug that was indicated for a very small subset of people over time becomes indicated and used for a much wider category.
CHRISTOPHER LANE: Fifty percent of the population defines itself as shy.
BROOKE GLADSTONE: Christopher Lane is the author of Shyness: How Normal Behavior Became a Sickness.
CHRISTOPHER LANE: An enormous number of people have a profound dislike of speaking in public but that doesn't mean they suffer from a psychiatric condition. And the effort on the part of these psychiatrists and the APA to broaden the net and include Internet addiction and compulsive buying disorder and apathy disorder, relational disorder, all of these are basically codes for everyday experiences and fears and anxieties that should not be represented in a psychiatric bible.
BROOKE GLADSTONE: Lane says the media compound the problem by reporting only the upper range of the estimate of those who may suffer from a potential disorder and by failing to report the size of the field studies, which often are quite small.
CHRISTOPHER LANE: I mean, one of the studies – it was a telephone survey to 526 urban Canadians – came out with self-reported accounts of social anxiety that ranged from 1.9 percent to 18.7 percent, but only the higher figure was reported in the subsequent media literature.
And what happens is then the public reads that, or hears it on the radio, and decides this is potentially a problem, certainly with social anxiety disorder because the drug maker in question, GlaxoSmithKline, spent over 94 million dollars on what it called a “public awareness campaign” for the disorder in question.
It wanted people basically to rethink whether they were suffering from just shyness and to ask themselves whether it might be something more serious, like social anxiety disorder.
DR. MICHAEL FIRST: The issue with all mental disorders is they're defined in terms of symptoms that we all experience every day as part of normal living.