Jerome Wakefield - Psychiatric Diagnoses: Science or Pseudoscience?

 

This is an interesting podcast from the good folks at the Institute for Ethics and Evolving Technologies (IEET) on the validity of psychiatric diagnoses - a very relevant topic here at the Evolution of Psychotherapy Conference. Many of the speakers we have heard so far do not use the DSM diagnostic protocols because they have little to do with the clients we see in our offices.



Jerome Wakefield is the author of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder (2007), All We Have to Fear: Psychiatry's Transformation of Natural Anxieties into Mental Disorders (2012), and several other books.

Psychiatric Diagnoses: Science or Pseudoscience?

Rationally Speaking
Posted: Dec 10, 2013 


Jerome Wakefield, DSW, PhD

The standard for diagnosis is the Diagnostic and Statistical Manual of Mental Disorders (DSM), which just released a 5th edition in 2013—but just how objective is it? This episode of Rationally Speaking features Dr. Jerome Wakefield, psychiatrist, PhD in philosophy, and author of "The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder." Julia, Massimo and Jerome talk about the arbitrariness of the DSM and the controversies around the boundaries of various mental disorders, including depression and sexual fetishes.



Jerome's pick: Bertran Russells's Autobiography

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Ethan Watters - The Problem With Psychiatry, the ‘DSM,’ and the Way We Study Mental Illness

From Pacific Standard magazine, Ethan Watters takes a look at the DSM and the history of diagnosis in psychiatry. Watters explains how the diagnostic manual determines which mental illnesses are "legitimate," which have legal standing, which get reimbursed by insurance, and how all of this has the subtext of defining our people and our culture.

The Problem With Psychiatry, the ‘DSM,’ and the Way We Study Mental Illness

Psychiatry is under attack for not being scientific enough, but the real problem is its blindness to culture. When it comes to mental illness, we wear the disorders that come off the rack.

June 3, 2013 • By Ethan Watters

In the 1880s, women by the tens of thousands displayed the distinctive signs of hysteria: convulsive fits, facial tics, spinal irritation, sensitivity to touch, leg paralysis. 

(ILLUSTRATION: MICHELLE THOMPSON)

Imagine for a moment that the American Psychiatric Association was about to compile a new edition of its Diagnostic and Statistical Manual of Mental Disorders. But instead of 2013, imagine, just for fun, that the year is 1880.

Transported to the world of the late 19th century, the psychiatric body would have virtually no choice but to include hysteria in the pages of its new volume. Women by the tens of thousands, after all, displayed the distinctive signs: convulsive fits, facial tics, spinal irritation, sensitivity to touch, and leg paralysis. Not a doctor in the Western world at the time would have failed to recognize the presentation. “The illness of our age is hysteria,” a French journalist wrote. “Everywhere one rubs elbows with it.”

Hysteria would have had to be included in our hypothetical 1880 DSM for the exact same reasons that attention deficit hyperactivity disorder is included in the just-released DSM-5. The disorder clearly existed in a population and could be reliably distinguished, by experts and clinicians, from other constellations of symptoms. There were no reliable medical tests to distinguish hysteria from other illnesses then; the same is true of the disorders listed in the DSM-5 today. Practically speaking, the criteria by which something is declared a mental illness are virtually the same now as they were over a hundred years ago.

The DSM determines which mental disorders are worthy of insurance reimbursement, legal standing, and serious discussion in American life. That its diagnoses are not more scientific is, according to several prominent critics, a scandal. In a major blow to the APA’s dominance over mental-health diagnoses, Thomas R. Insel, director of the National Institute of Mental Health, recently declared that his organization would no longer rely on the DSM as a guide to funding research. “The weakness is its lack of validity,” he wrote. “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. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever.” As an alternative, Insel called for the creation of a new, rival classification system based on genetics, brain imaging, and cognitive science.

This idea—that we might be able to strip away all subjectivity from the diagnosis of mental illness and render psychiatry truly scientific—is intuitively appealing. But there are a couple of problems with it. The first is that the science simply isn’t there yet. A functional neuroscientific understanding of mental suffering is years, perhaps generations, away from our grasp. What are clinicians and patients to do until then? But the second, more telling problem with Insel’s approach lies in its assumption that it is even possible to strip culture from the study of mental illness. Indeed, from where I sit, the trouble with the DSM— both this one and previous editions—is not so much that it is insufficiently grounded in biology, but that it ignores the inescapable relationship between social cues and the shifting manifestations of mental illness.
It is true that the DSM has a great deal of influence in modern America, but it may be more of a scapegoat than a villain.

PSYCHIATRY TENDS NOT TO learn from its past. With each new generation, psychiatric healers dismiss the enthusiasms of their predecessors by pointing out the unscientific biases and cultural trends on which their theories were based. Looking back at hysteria, we can see now that 19th-century doctors were operating amidst fanciful beliefs about female anatomy, an assumption of feminine weakness, and the Victorian-era weirdness surrounding female sexuality. And good riddance to bad old ideas. But the more important point to take away is this: There is little doubt that the symptoms expressed by those thousands of women were real.

The resounding lesson of the history of mental illness is that psychiatric theories and diagnostic categories shape the symptoms of patients. “As doctors’ own ideas about what constitutes ‘real’ dis-ease change from time to time,” writes the medical historian Edward Shorter, “the symptoms that patients present will change as well.”

This is not to say that psychiatry wantonly creates sick people where there are none, as many critics fear the new DSM-5 will do. Allen Frances—a psychiatrist who, as it happens, was in charge of compiling the previous DSM, the DSM-IV—predicts in his new book, Saving Normal, that the DSM-5 will “mislabel normal people, promote diagnostic inflation, and encourage inappropriate medication use.” Big Pharma, he says, is intent on ironing out all psychological diversity to create a “human monoculture,” and the DSM-5 will facilitate that mission. In Frances’ dystopian post-DSM-5 future, there will be a psychoactive pill for every occasion, a diagnosis for every inconvenient feeling: “Disruptive mood dysregulation disorder” will turn temper tantrums into a mental illness and encourage a broadened use of antipsychotic drugs; new language describing attention deficit disorder that expands the diagnostic focus to adults will prompt a dramatic rise in the prescription of stimulants like Adderall and Ritalin; the removal of the bereavement exclusion from the diagnosis of major depressive disorder will stigmatize the human process of grieving. The list goes on.

In 2005, a large study suggested that 46 percent of Americans will receive a mental-health diagnosis at some point in their lifetimes. Critics like Frances suggest that, with the new categories and loosened criteria in the DSM-5, the percentage of Americans thinking of themselves as mentally ill will rise far above that mark.

But recent history doesn’t support these fears. In 1994 the DSM-IV—the edition Frances oversaw—launched several new diagnostic categories that became hugely popular among clinicians and the public (bipolar II, attention deficit hyperactivity disorder, and social phobia, to name a few), but the number of people receiving a mental-health diagnosis did not go up between 1994 and 2005. In fact, as psychologist Gary Greenberg, author of The Book of Woe, recently pointed out to me, the prevalence of mental health diagnoses actually went down slightly. This suggests that the declarations of the APA don’t have the power to create legions of mentally ill people by fiat, but rather that the number of people who struggle with their own minds stays somewhat constant.

What changes, it seems, is that they get categorized differently depending on the cultural landscape of the moment. Those walking worried who would have accepted the ubiquitous label of “anxiety” in the 1970s would accept the label of depression that rose to prominence in the late 1980s and the 1990s, and many in the same group might today think of themselves as having social anxiety disorder or ADHD.

Viewed over history, mental health symptoms begin to look less like immutable biological facts and more like a kind of language. Someone in need of communicating his or her inchoate psychological pain has a limited vocabulary of symptoms to choose from. From a distance, we can see how the flawed certainties of Victorian-era healers created a sense of inevitability around the symptoms of hysteria. There is no reason to believe that the same isn’t happening today. Healers have theories about how the mind functions and then discover the symptoms that conform to those theories. Because patients usually seek help when they are in need of guidance about the workings of their minds, they are uniquely susceptible to being influenced by the psychiatric certainties of the moment. There is really no getting around this dynamic. Even Insel’s supposedly objective laboratory scientists would, no doubt, inadvertently define which symptoms our troubled minds gravitate toward. The human unconscious is adept at speaking the language of distress that will be understood.

WHY DO PSYCHIATRIC DIAGNOSES fade away only to be replaced by something new? The demise of hysteria may hold a clue. In the early part of the 20th century, the distinctive presentation of the disorder began to blur and then disappear. The symptoms began to lose their punch. In France this was called la petite hysterie. One doctor described patients who would “content themselves with a few gesticulatory movements, with a few spasms.” Hysteria had begun to suffer from a kind of diagnostic overload. By 1930s or so, the dramatic and unmistakable symptoms of hysteria were vanishing from the cultural landscape because they were no longer recognized as a clear communication of psychological suffering by a new generation of women and their healers.

It is true that the DSM has a great deal of influence in modern America, but it may be more of a scapegoat than a villain. It is certainly not the only force at play in determining which symptoms become culturally salient. As Frances suggests, the marketing efforts of Big Pharma on TV and elsewhere have a huge influence over which diagnoses become fashionable. Some commentators have noted that shifts in diagnostic trends seem uncannily timed to coincide with the term lengths of the patents that pharmaceutical companies hold on drugs. Is it a coincidence that the diagnosis of anxiety diminished as the patents on tranquilizers ran out? Or that the diagnosis of depression rose as drug companies landed new exclusive rights to sell various antidepressants? Consider for a moment that the diagnosis of depression didn’t become popular in Japan until Glaxo-Smith-Klein got approval to market Paxil in the country.

Journalists play a role as well: We love to broadcast new mental-health epidemics. The dramatic rise of bulimia in the United Kingdom neatly coincided with the media frenzy surrounding the rumors and subsequent revelation that Princess Di suffered from the condition. Similarly, an American form of anorexia hit Hong Kong in the mid-1990s just after a wave of local media coverage brought attention to the disorder.

The trick is not to scrub culture from the study of mental illness but to understand how the unconscious takes cues from its social settings. This knowledge won’t make mental illnesses vanish (Americans, for some reason, find it particularly difficult to grasp that mental illnesses are absolutely real and culturally shaped at the same time). But it might discourage healers from leaping from one trendy diagnosis to the next. As things stand, we have little defense against such enthusiasms. “We are always just one blockbuster movie and some weekend therapist’s workshops away from a new fad,” Frances writes. “Look for another epidemic beginning in a decade or two as a new generation of therapists forgets the lessons of the past.” Given all the players stirring these cultural currents, I’d make a sizable bet that we won’t have to wait nearly that long.

This brief article comes from MadInAmerica, a great blog/site that offers counter-truth to the mainstream beliefs about mental illness and medicating mental illness. The article errs a bit in citing NIMH Director Thomas Insel's comment: ‘Patients…deserve better’ - Insel is completely on-board with the biomedical model, which is why he is rejecting the DSM-5. For Insel, the DSM-5 does not go far enough in making all mental health issues "brain-based." In fairness, Johnstone recognizes this a little later in the piece.

Some of the backlash against the BPS statement claims that they reject any biological components. But this is inaccurate - they simply recognize biological markers as one component of an often complicated etiology for mental illness.

For me, the biggest issue with the biological model is that they are looking at people with mental illness and identifying differences in their brains from those who do not have similar symptoms. The question is not in the differences, it's in the etiology. Researchers such as Allan Schore have written extensively on how developmental issues wire the brain in different ways. Schore's model combines insights from neuroscience, attachment theory, and psychodynamic processes into a more comprehensive etiology.

Likewise, Daniel Siegel and others have shown that the brain can be rewired - faulty attachment can be repaired through a healthy relationship with another person (sometimes, but not always, a therapist), and that we can do a great deal on our own to rewire the brain (neuroplasticity is the foundation of these models) through practices such as meditation, mindfulness, and active imagination.

UK Clinical Psychologists Call for the Abandonment of Psychiatric Diagnosis and the ‘Disease’ Model

Lucy Johnstone
May 13, 2013

In a bold and unprecedented move for any professional body, the UK Division of Clinical Psychology, a sub-division of the British Psychological Society, issued a Position Statement today calling for the end of the unevidenced biomedical model implied by psychiatric diagnosis. The key message of the statement is:

“The DCP is of the view that it is timely and appropriate to affirm publicly that the current classification system as outlined in DSM and ICD, in respect of the functional psychiatric diagnoses, has significant conceptual and empirical limitations. Consequently, there is a need for a paradigm shift in relation to the experiences that these diagnoses refer to, towards a conceptual system not based on a ‘disease’ model.”

In brief, the argument is that the so-called ‘functional’ diagnoses – schizophrenia, bipolar disorder, personality disorder, ADHD and so on – are not scientifically valid categories and are often damaging in practice. The statement argues that we already have alternatives, such as psychological formulation, and that there is a need to work in partnership with service users and professional groups, including psychiatrists, in order to develop these further.

The story made the front page of one of the UK’s best-known broadsheets, the Observer, sister paper to the Guardian, and there was a double-page spread inside (“Medicine’s big new battleground: does mental illness really exist?“, and “Psychiatrists under fire in mental health battle“). Within hours, over 500 comments (and counting) had been posted online, and the articles were being re-tweeted round the world. The articles quoted me, Professor Mary Boyle (author of ‘Schizophrenia: a Scientific Delusion?’) Eleanor Longden, researcher, campaigner and survivor, and Oliver James, psychologist and journalist, in support of the call for a non-medical approach to mental distress.

Needless to say, there has been as much backlash as appreciation. Perhaps most predictably, Allen Frances, outspoken opponent of DSM-5, described the document (without having read it) as ‘extremist posturing by British Psychological Society, just as silly as DSM-5 and NIMH – why not a balanced biopsychosocial model’ (@AllenFrancesMD 12.5.13.) Many took advantage of a somewhat unhelpful online headline to dismiss the debate as inter-professional ‘turf wars’, while others accused the DCP of ignoring the role of biology.

The actual statement makes it absolutely clear that these are misrepresentations. The DCP specifically states that ‘This position should not be read as a denial of the role of biology in mediating and enabling all forms of human experience, behaviour and distress.’ The statement also explicitly says that the argument is about ways of thinking, not about particular professions. The ‘turf wars’ accusation is particularly wide of the mark given that the DCP statement is simply a more measured reiteration of recent comments by some of the world’s most eminent psychiatrists: Allen Frances himself described DSM-5 as ‘deeply flawed and scientifically unsound’, while Dr Thomas Insel, NIMH director, said ‘Patients…deserve better’. Former NIMH director Dr Steven Hyman, was even blunter: he called DSM-5 ‘totally wrong, an absolute scientific nightmare’ and in response, the Chair of the DSM-5 committee, Dr David Kupfer, admitted “We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting.”

The main difference – and of course it is a crucial one – between the position of these eminent psychiatrists and the DCP is that the former are determined to pursue the biomedical model at all costs. Indeed, NIMH has (as discussed on this site) announced the intention of launching a 10-year programme to pin down, once and for all, the elusive biomarkers that have evaded researchers so far. The project starts from the remarkably unscientific position of assuming what needs to be proved: in their words that ‘mental disorders are biological disorders.’ Flawed as this enterprise is, it will allow traditionalists to continue to claim that ‘We’re getting there – honestly!’ In the meantime, the overwhelming amount of evidence for psychosocial causal factors is once again relegated to a back seat.

I was a member of the DCP working party which took 2 years to arrive, painstakingly and carefully, to this consensus statement. I believe there is nothing more important that a professional body can do than speak the truth about the evidence – and that is what this statement does. Nevertheless, given the nature of the issues, it is a brave move. I hope that other organisations will take heart – as they did from the original BPS response to the DSM-5 consultations in June 2011 – and join the DCP in calling for a more humane and evidence-based approach to mental distress.

Links to BPS consultation responses on DSM-5

• Society Statement on DSM-5 (12/12/2011)
• The British Psychological Society Still has Concerns Over DSM-5 (6/20/2012)

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.

PTSD in the DSM-5 - Review of Changes

Now that the DSM-5 revision is completed and going to press, we can begin to assess some of the changes. For me, one of the major areas of interest is the PTSD diagnosis.

It seems a good move to take it out of the anxiety category and place it in a new category of Trauma- and Stress-or-Related Disorders. There are also four symptom clusters now, with the addition of negative cognitions and mood: Re-experiencing, Avoidance, Negative cognitions and mood, and Arousal.

Another important change is to include two subtytpes, Preschool’ for children younger than 6 years, and ‘Dissociative’ for people with prominent dissociative symptoms.

Here is the full summary from Trauma Recovery.

PTSD in the DSM-5

Posted on 11 April 2013



What is going to change in the criteria for a PTSD diagnosis in the 5th edition of the psychiatry ‘bible’, the Diagnostic and Statistical Manual of Mental Disorders?

The DSM-5 is to be published in May this year but some information on the changes starts to trickle through…

Below are the most important changes, drawn from a handout of the American Psychiatric Association:

1. PTSD will no longer be classified as an anxiety disorder. It will fall under the new ‘Trauma- and Stress-or-Related Disorders’.

2. The definition of trauma exposure will change: it no longer requires someone to respond with fear, helplessness or horror to the event. The exposure to actual or threatened death, serious injury or sexual violation will be central to the definition, with media exposure being explicitly excluded unless it is work-related.

3. There will be four instead of three symptom clusters:

• Re-experiencing
• Avoidance
• Negative cognitions and mood
• Arousal

The new cluster of negative cognitions and mood includes estrangement from others, a persistent and distorted sense of blame of self/others, diminished interest in activities and inability to remember key aspects of the event. The arousal cluster will include more aggression-related symptoms than it did in the DSM-IV.

4. There will be two subtypes: ‘Preschool’ for children younger than 6 years, and ‘Dissociative’ for people with prominent dissociative symptoms.

What do you think of these changes? Do they align with your experience? And if you work with the DSM, will you start applying the DSM-5 criteria right away or do you expect to stick with the DSM-IV criteria for a while?