Saturday, February 13, 2010

Is All Mental Illness Organic?

One of the changes proposed for the new DSM-V (see the APA's site for the DSM-V) is the collapse of Axes I, II, and III into a single group. I have some serious issues with this, which I will explain below. Here is what they have posted:

Classification Issues Under Discussion

There have been frequent and continued discussions about refining the classification of disorders in DSM-5, including the multi-axial system used by clinicians to document diagnoses and variables of clinical importance. A subgroup has been charged with examining the utility of Axis III, which is currently used in DSM-IV to record general medical conditions related to the patient’s mental disorder. The subgroup has recommended that DSM-5 collapse Axes I, II, and III into one axis that contains all psychiatric and general medical diagnoses. This change would bring DSM-5 into greater harmony with the single-axis approach used by the international community in the World Health Organization’s (WHO) International Classification of Diseases (ICD). Axis IV is currently where clinicians document psychosocial and environmental problems, such as whether a patient is having housing or economic problems or problems with his/her primary support group. The group working on Axis IV is examining the codes in the 10th edition of the ICD that might be comparable to the concepts presented in DSM-IV. Using these codes would allow DSM to more closely parallel the ICD as well. Finally, regarding Axis V, which allows clinicians to rate a patient’s overall level of functioning, the Impairment and Disability Study Group is discussing ways in which disability and distress can be better assessed in DSM-5. They have recommended that DSM-5 more closely follow the concepts outlines in the WHO International Family of Classifications, in which disorders and their associated disabilities are conceptually distinct and assessed separately.
A little explanation might be helpful here for those not familiar with the DSM classification system. This explanation comes from Wikipedia:

Multi-axial system

The DSM-IV organizes each psychiatric diagnosis into five levels (axes) relating to different aspects of disorder or disability:

  • Axis I: Clinical disorders, including major mental disorders, and learning disorders
  • Axis II: Personality disorders and mental retardation (although developmental disorders, such as Autism, were coded on Axis II in the previous edition, these disorders are now included on Axis I)
  • Axis III: Acute medical conditions and physical disorders
  • Axis IV: Psychosocial and environmental factors contributing to the disorder
  • Axis V: Global Assessment of Functioning or Children's Global Assessment Scale for children and teens under the age of 18

Common Axis I disorders include depression, anxiety disorders, bipolar disorder, ADHD, autism spectrum disorders, phobias, and schizophrenia.

Common Axis II disorders include personality disorders: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder, avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder, and mental retardation.

Common Axis III disorders include brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders.

So the new recommendation is to collapse all three of these axes into a single classification. Essentially, what this proposal means is that all mental illness will be correlated with medical / brain states. The big push with the DSM over the last two decades has been to make it a fully medical model, and this is the last big step.

The hidden assumption is that brain chemistry causes mental illness. But this has never been proven in any real sense for most mental suffering. It is equally as likely that emotional experience, psychological trauma, and other experience rewires the brain to cause dysfunction. The reality is that it is probably a little of both.

However, we know that we can change the brain with meditation and other techniques (see here, here, here, and here, just for starters). If positive experience can change brain-wave patterns, neurotransmitters, and the physical structure of the brain, it seems obvious that negative experience can as well. For example, we know that PTSD (and chronic stress) changes the brain: see here, here, here, and here.

If experience can change the brain in both positive and negative ways, the biomedical model of organic etiology for mental illness becomes suspect at best.

However, this is the direction the American Psychiatric Association (remember, psychiatrists are medical doctors first, with some training in mental illness) has been moving for decades. By collapsing the first three axes of the diagnostic tree (which are necessarily useful in their current form) into a single category, the APA achieves its goal of imposing the biomedical model on all mental illness.

Another complication to all of this is that personality disorders (Axis II) are distinctly different than other forms of mental illness. People suffering from Axis I disorders (depression, anxiety disorders, bipolar disorder, ADHD, phobias, and - to a lesser extent - schizophrenia) know that something is wrong and they want to be better (the symptoms are egodystonic). This is not the case, however, with the Axis II personality disorders (see the citation above). A narcissistic or borderline personality does not think there is anything wrong with them but, rather, thinks it is everyone else who has the problem (personality disorders are egosyntonic).

Personality disorders tend to also show distinct differences in brain anatomy, just as Axis I disorders, but they are far more resistant to change - and few if any of them respond well to pharmaceutical interventions.

This is one change in the DSM that needs professional opposition from those of us who understand that the biomedical piece is only one part of the puzzle that is mental illness. Please follow the link at the top to leave your comments on the proposed changes.

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