Monday, May 20, 2013

Robin S. Rosenberg - Abnormal Is the New Normal

As the DSM-5 begins to hit the shelves in the next week, people are already lining up to throw rotten vegetables at it. And with good reason. This version of the diagnostic bible for psychiatrists, psychologists, counselors, marriage and family therapists, and social workers has gone alarming deep into the realm of making basic human experience pathological.

Fortunate for me, I generally only use one diagnosis - PTSD. Occasionally, I need to look up the code for major depressive disorder, or a substance abuse disorder, or much more rarely, an Axis II personality disorder. If it were up to me, the DSM would cease to exist as anything other than an index for billing insurance.

In this article from Slate, Robin Rosenberg offers her criticisms of the DSM-5.

Abnormal Is the New Normal

Why will half of the U.S. population have a diagnosable mental disorder?

By Robin S. Rosenberg  |  Posted Friday, April 12, 2013

Illustration by Robert Neubecker.

Beware the DSM-5, the soon-to-be-released fifth edition of the “psychiatric bible,” the Diagnostic and Statistical Manual. The odds will probably be greater than 50 percent, according to the new manual, that you’ll have a mental disorder in your lifetime.

Although fewer than 6 percent of American adults will have a severe mental illness in a given year, according to a 2005 study, many more—more than a quarter each year—will have some diagnosable mental disorder. That’s a lot of people. Almost 50 percent of Americans (46.4 percent to be exact) will have a diagnosable mental illness in their lifetimes, based on the previous edition, the DSM-IV. And the new manual will likely make it even "easier" to get a diagnosis.

If we think of having a diagnosable mental illness as being under a tent, the tent seems pretty big. Huge, in fact. How did it happen that half of us will develop a mental illness? Has this always been true and we just didn’t realize how sick we were—we didn’t realize we were under the tent? Or are we mentally less healthy than we were a generation ago? What about a third explanation—that we are labeling as mental illness psychological states that were previously considered normal, albeit unusual, making the tent bigger. The answer appears to be all three.

Second, we really are getting “sicker.” The high prevalence of mental illness in the United States isn’t only because we’ve gotten better at detecting mental illness. More of us are mentally ill than in previous generations, and our mental illness is manifesting at earlier points in our lives. One study supporting this explanation took the scores on a measure of anxiety of children with psychological problems in 1957 and compared them with the scores of today’s average child. Today’s children—not specifically those identified as having psychological problems, as were the 1957 children—are more anxious than those in previous generations.First, we’ve gotten better at detecting mental illness and doing so earlier in the course of the illness. For decades, mental health clinicians, physicians, the U.S. surgeon general’s office, and various state and local agencies have been advocating for better detection of mental illness. If we are better at spotting it, we can treat it. And if we detect it earlier, we can, hopefully, intervene to reduce the intensity and/or frequency of symptoms. For instance, people who decades ago may have had undiagnosed attention deficit hyperactivity disorder, depression, or substance abuse are now more likely to have their problems recognized and diagnosed. But the increased awareness and detection translates into a higher rate of mental illness.

Another study compared cohorts of American adults on the personality trait of neuroticism, which indicates emotional reactivity and is associated with anxiety. Americans scored higher on neuroticism in 1993 than they did in 1963, suggesting that as a population we are becoming more anxious. Another study compared the level of narcissism among cohorts of American college students between 1982 and 2006 and found that more recent cohorts are more narcissistic.

An additional study supports the explanation that more people are diagnosed with mental illness because more of us have mental illness: The more recently an American is born, the more likely he or she is to develop a psychological disorder. Collectively, this line of research indicates that more is going on than simply better detection of mental illness.

Here’s a third explanation for the increased prevalence of mental illness, one that implies something important about our culture: What was once considered psychological healthy (or at least not unhealthy) is now considered to be mental illness. Some of the behaviors, thoughts, and feelings that were within the then-normal range of human experience are now deemed to be in the pathological part of the continuum. Thus, the actual definition of mental illness has broadened, creating a bigger tent with more people under it. This explanation implies that we, as a culture, are more willing to see mental illness in ourselves and in others.

The increasing prevalence is in part because each edition of the DSM has increased the overall number of disorders. The DSM-I, from 1952, listed 106; the DSM-III, from 1980, listed 265, and the current DSM-IV has 297. (Complaints about this ever-increasing total led the chair of the DSM-5 task force, David Kupfer, to announce that the total number of disorders in DSM-5 will not increase. One way to add new diagnoses—and DSM-5 will—but not increase the total is to make a disorder in a previous edition into a “subtype” of another disorder in the new edition, thereby keeping two diagnostic entities, but with one subsumed under another.)

The increasing number of disorders comes about because some “problems” that were not previously considered to be mental illness were reclassified as such by their inclusion in the DSM—and it is the DSM that functionally defines mental illness in the United States.

As an example, prior to the DSM-IV, there was no diagnosis of Asperger’s syndrome; rather, people with what is now called Asperger’s would have been diagnosed with autism (“high functioning” autism) or not diagnosed at all. This syndrome was added as a separate disorder to highlight the different forms that autism symptoms may take and to focus research on the most effective treatments for Asperger’s. Others, however, claimed that the diagnostic label pathologized quirkiness. (In DSM-5, Asperger’s is classified as a subtype of a newly consolidated single diagnosis “autism spectrum disorder.”)

Some of the disorders added to DSM editions are primarily—or wholly—medical in nature. One example is the diagnosis of “breathing-related sleep disorder,” which arises from medical problems that interfere with sleep. One such medical problem is obstructive sleep apnea, which occurs when the muscles of the throat relax so much during sleep that they narrow or block the airway. Throughout the night, people with obstructive sleep apnea have their deep sleep cut short as they relax because they stop breathing; once in a lighter phase of sleep, they breathe normally again. This disorder is not a mental disorder, but a medical one.

Another example is the “disorder” “caffeine intoxication,” characterized by at least five symptoms after consuming the equivalent of two to three cups of coffee: restlessness, gastrointestinal problems, difficulty sleeping, nervousness, and rapid heartbeat. To meet the diagnosis, the symptoms must impair functioning in some way. It’s hard to believe that an episode of too much coffee or Red Bull constitutes a mental disorder, but there you have it. DSM-5 has added “caffeine withdrawal” as a diagnosis—characterized by a withdrawal headache plus at least one other symptom, such as drowsiness, that interferes with some aspect of functioning. With disorders like this in the DSM, it’s no wonder that half of Americans will have a diagnosable disorder in their lifetimes. The wonder is why more Americans won’t!

Asperger's syndrome, which will be redefined into the broader category of autism spectrum disorders in the fifth edition of the Diagnostic and Statistical Manual, is one of several changes to the "psychiatry bible." Above, Matthew Kolen was diagnosed at age 8 with Asperger's. Photo by Shannon Stapleton/Reuters

In addition to classifying some medical disorders as mental disorders, the DSM also has been nibbling at the edges of “normal” by reclassifying as pathological the patterns of thoughts, feelings, or behaviors that were previously considered normal (albeit perhaps weird or odd). For instance, people who are extremely shy and concerned about how others might evaluate them, and who thus avoid certain types of activities, might be diagnosed with “avoidant personality disorder.” These same characteristics didn’t used to be considered pathological, and in some other cultures they are not considered to be so.

Another way that the increased prevalence of mental illness occurs is by lowering the threshold of what it takes to be diagnosed with a given disorder. For instance, DSM-5 will change in the criteria for “generalized anxiety disorder,” a disorder that involves excessive and persistent worrying. Whereas the criteria in DSM-IV required three out of six symptoms of worrying, only one symptom is needed in DSM-5. Similarly, whereas in DSM-IV the symptoms must have persisted for at least six months, in DSM-5 the duration has been reduced to three months. So if you are excessively worried for three months about your finances or your health or that of a family member (to the point where you can’t control the worries), you would be considered to have a disorder, whereas in the past you would not have.

One effect of a bigger mental illness tent is that there are fewer people standing outside the tent. Although the next edition of the DSM might not increase the overall number of disorders, if the criteria are loosened (that is, if it takes fewer symptoms or less severity to meet the criteria for diagnosis), then more people would qualify for a disorder. There are, and probably will continue to be, fewer and fewer people who will live their lives in relatively good mental health according to the DSM.

The normal trials and tribulations of life—the periods of sadness, or worry, of anxiety, or grief, of difficulty sleeping, of drinking too much caffeine or having caffeine withdrawal headaches—have been pathologized. They’ve been made into mental illnesses. More “normal” thoughts, feelings, and actions have come to merit a diagnosis. This way toward providing a bigger tent for mental illness leaves us with an increasingly restricted definition of mental health and can make us all more likely to see mental illness even when it isn’t there—where there is just normal human struggle. We can become so used to seeing psychopathology that we think—erroneously—that being odd or having difficulties must be an expression of mental illness.

What is going in our culture that allows for this expanding definition of mental illness? There are many explanations. The first is related to payment for treatment. Psychological treatments and medications can be useful for a variety of problems, but for those treatments to be even partially paid for by health insurance companies, the problems must have a diagnosis. It’s not enough that there’s a problem that’s being addressed. It has to be a problem. (Of course, if you treat a problem before it becomes a mental illness, the health insurance company will have ended up saving a significant amount of money, but they don’t pay for early mental health intervention—there has to be a problem. But that’s a story beyond the scope of this article.)

Second, pharmaceutical companies search for ever-wider markets for their products. When more people are diagnosed with a given disorder (perhaps because of less stringent criteria), or a new diagnosis is created, it widens the market for their drugs. They push for “off-label” uses of their medications that in some way reduce a problem, and then they push for that “problem” to be redefined as a problem. In fact, DSM-5 and the pharmaceutical industry have a significant number of connections: One study found that 70 percent of DSM-5 task-force members have financial ties to the pharmaceutical industry.

Third is increased work expectations. The pace and demands of many jobs have increased. Many companies maintain as few workers as possible to get the work done, and if an employee can’t reliably perform up to the (more intense) pace, he or she risks getting fired. If an employee has been feeling “down” or “anxious” enough that it’s not possible to work at near 100 percent or even 90 percent productivity, a pill that promises to counteract the symptoms of a newly identified psychological disorder seems like a better alternative than limping along, worried about being fired on top of other problems.

Fourth, in our era of instant gratification, ushered along by online shopping, downloaded entertainment, and the immediate access to the world available through the Internet, if we have problems, we want a quick fix. If a medication will help lessen uncomfortable thoughts or feelings or maladaptive behavior, we are receptive to medication. To quote Sami Tamimi, an adolescent psychiatrist in the United Kingdom, “Like fast food, recent medication-centered practice comes from the most aggressively consumerist society (USA), feeds on people’s desire for instant satisfaction and a ‘quick fix,’ fits into a busy life-style.” But if we’re going to take a medication, we need to have a problem that is being treated—at least to get those doctors’ visits reimbursed by the insurance company.

Fifth, certain diagnoses—along with other criteria—make the sufferer eligible for government services or programs or supplementary educational services, or allow them to claim legal rights of nondiscrimination. People who feel they or their loved ones could benefit from those services may advocate for a widening in criteria that enables more people to be diagnosed and thus eligible for those services. For instance, the diagnostic criteria for autism will change with DSM-5, and people diagnosed with the disorder—per DSM-IV—and their loved ones have vociferously expressed their concern that the new criteria will be more restrictive and thus will exclude some who currently have the diagnosis.

Finally, I think there is an additional reason: As our lives take on an even more frantic pace and our workload becomes ever greater, having a diagnosis gives a name to the suffering we feel and the hope that with a label can come relief. In dark or difficult times, hope is essential. But I’m not sure that ultimately labeling half of us with a mental disorder is the best way to give people realistic hope. Having a diagnosable mental illness has almost become the new “normal.” As a society, we have an opportunity to think about how we define mental health and illness. It shouldn’t only be up to the authors of the DSM.

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