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Why we need a manual on mental disorders

By Katrina vanden Heuvel

Few books command the biblical respect and status of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, and this “objective” authority on the most subjective branch of medicine, last revised in 1994, is currently being retooled for the twenty-first century. It is a monumental undertaking. “Anything you put in that book,” Dr. Michael First, professor of psychiatry at Columbia and editor of the current version, said to the New York Times, “any little change you make has huge implications not only for psychiatry but for pharmaceutical marketing, research, for the legal system, for who’s considered to be normal or not, for who’s considered disabled.”

Critical assessments of DSM’s next edition include that it will serve as a vehicle by which to sell more drugs and that it will make health insurance more difficult to obtain. It is easier to rationalize prescribing a pharmaceutical for someone with a DSM-certified problem (“hypersexual disorder,” for example, is proposed for people who suffer from an unusually high sex drive) than for someone without, just as it is easier to justify denial of coverage to someone who appears to be headed for a lifetime of expensive monthly prescriptions than for someone whose chart is diagnosis-free. Indeed, an edition of DSM chock-full of new disorders (such as “Internet addiction”) runs the risk of “massively pathologizing people,” said Dr. Jerome C. Wakefield, a professor of social work and psychiatry at New York University.

But the critics should realize that a definitive and authoritative reference is an essential tool for alleviating the pain and suffering of those who are afflicted. In the debates over the new edition, it’s easy to forget that treatment is the end goal of psychiatry. Sure, a DSM taken to its logical extreme would need to list 6.8 billion disorders, one for each nut on the planet. But going in the opposite direction, having fewer or inadequate guidelines to help professionals identify mental illnesses and the proper treatments for them, could be worse. The APA has a nearly impossible -- yet massively important -- job on its hands.

By Katrina vanden Heuvel  | February 12, 2010; 1:19 PM ET
Categories:  vanden Heuvel  | Tags:  Katrina vanden Heuvel  
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Comments

We need it to be able to diagnose the abnormal behaviors so many of our politicians display so frequently.

Posted by: edismae | February 12, 2010 3:43 PM | Report abuse

"It is easier to rationalize prescribing a pharmaceutical for someone with a DSM-certified problem (“hypersexual disorder,” for example, is proposed for people who suffer from an unusually high sex drive) than for someone without, ...Indeed, an edition of DSM chock-full of new disorders (such as “Internet addiction”) runs the risk of “massively pathologizing people,” said Dr. Jerome C. Wakefield, a professor of social work and psychiatry at New York University."

You can only wonder what role semantics and sociology play in psychiatry, when someone with an unusually high sex drive now has a DSM V disorder called "hypersexual disorder", but a man consumed with having sex only with men or a woman consumed with having sex only with women has no DSM V sexual dysfunction and no diagnosis. This is more like "Alice in Wonderland" than medical science. Words mean what I say they mean, said Humpty Dumpty. One wonders whether Humpty was a board certified psychiatrist.

Posted by: captn_ahab | February 12, 2010 4:22 PM | Report abuse

One gathers ponophobia is not provisioned a code apart from other phobias. A definite deficiency.

Posted by: Martial | February 12, 2010 4:35 PM | Report abuse

As a psychiatrist not directly involved in the DSM-5 process, I commend Ms.vanden Heuvel for recognizing that the task of classifying so-called "mental disorders" is extraordinarily complex and difficult. We have had an intense debate on the DSM process, and on the proposed new criteria, on the Psychiatric Times website (www.psychiatrictimes.com)--the publication I edit.

It is certainly true that "values" in a very broad sense influence what conditions are considered "disorders" or "diseases." This is true not just in psychiatry, but in general medicine as well. Some of these values are bound up in very general ideas of what constitutes "health", "disease", "abnormality", etc. But, contrary to one of your readers, psychiatric diagnosis is not merely a matter of "semantics and sociology."

We begin from an ethical foundation of seeking to relieve suffering and incapacity. Indeed, the very word "disease" began with its awareness of dis-ease; that is, a state of discomfort and dysfunction. Most of the major DSM categories, both in the current DSM-IV and in the proposed DSM-V, require not merely an
"abnormality" (however defined); but also,
"clinically significant distress or impairment".

Of course, one can debate how to measure and define those terms--but most people know it when they see it. In fact, the concept of disease arose because ordinary people--not experts-- were able to recognize suffering and incapacity among their family and loved ones.

To some degree, the DSM process has gotten into trouble, in my view, when it has strayed from the concepts of suffering and incapacity, and instead, focused on "abnormality" or behaviors that are not culturally approved. That was one reason homosexuality used to be classified as a mental disorder, but is no longer so classified.

We do run into conundrums when we consider, as one of your readers notes, something like "hypersexuality"--what some wags have described as "just plain good luck"! Clearly, we must look at the degree of suffering and incapacity of the individual before we declare him or her to have a "disease" or "disorder." Ultimately, we would also like to find biological and genetic "markers" or correlates for our diagnoses, and we have made some progress with respect to schizophrenia, bipolar disorder, and major depression. But we have a long way to go.

The bottom line is that the DSM-V is only as good as its ability to help us understand and mitigate the suffering and incapacity of our patients.

Ronald Pies MD

Posted by: rpies1 | February 12, 2010 4:44 PM | Report abuse

Too bad there isn't a recognition of recovery from the illnesses described in these books. Once labeled, the patient remains forever uninsurable even if treatment has been successful.

Posted by: crossroadsteam | February 12, 2010 5:20 PM | Report abuse

Spreading the cult of psychiatry to drug the world into oblivion is the only purpose of this hogwash nonsense lunatic whitewash piece of trash.

Children on Ritalin with no future, drugged soldiers losing wars, managers and bankers on Prozac running the economy into the ground - psychiatry has plotted a bright future for America.

DSM will be used as evidence when the criminals behind it will be brought to justice.


Posted by: ratl | February 12, 2010 8:39 PM | Report abuse

rpies1, fascinating to read such an informed and informative comment.

I do have this question:

You write "Ultimately, we would also like to find biological and genetic "markers" or correlates for our diagnoses, and we have made some progress...."

How does that hope square with the peculiar fact that some so-called mental disorders seem culturally specific? Isn't it possible that in fact some of these cases are indeed disorders that arise at the level of operations of thought, with no corresponding biological substrate that's any different than a "normal" one?

Your sentence quoted above strikes me as more of a statement of faith than a summary of empirical observations.

Again, I'm not being ironic in expressing appreciating for your comment, and don't mean to be wisecracking, just expressing a serious doubt about your programme.

Posted by: douglaslbarber | February 12, 2010 8:43 PM | Report abuse

It's just putting more labels on the slings and arrows of everyday life so that a dubious profession can justify its existence. There is money to be made in convincing people that there is something wrong with them and that they need to be fixed when actually they are just dealing with life.

Posted by: pjs1965 | February 12, 2010 8:43 PM | Report abuse

It worked at Ft. Hood. Or did it? Maybe that is why they "practice medicine".

Posted by: staterighter | February 12, 2010 9:21 PM | Report abuse

As the DSM has become larger and has defined increasingly more life issues as being "mental disorders," so to has the incidence of those and many other mental disorders, in the same time frame, increased.

I challenge anyone to prove that the approach taken in the newer versions of the DSM has let to decreased suffering and has improved human adaptation in our country. We now have an army of counselors, an incredible array of drugs, dozens of not hundreds of different therapies, and a highly detailed manual of mental disorders, yet we are no better off than before we had them.

Perhaps we should be questioning some basic assumptions regarding whether psychiatry, medicine, psychology, and counseling are really taking the right approach to enhancing our lives. And whether a new DSM, as "valid" as it tries to be, really moves us in that direction.

There are a few true mental illnesses (Schizophrenia, Bipolar Disorder, Autism, etc.). Maybe all of the rest are just life. The "medicalization" of "life" since WWII has perhaps, overall, been a colossal failure.

Posted by: dfgrayb | February 12, 2010 9:35 PM | Report abuse

As a psychologist in practice for some 20 years I deal every day with people with "clinically significant suffering and disability." I would like to express my appreciation for Dr. Pies's note about some of the thorny issues that underlie the DSM revisions.

I would also like to point out that, at this point, the DSM-IV, DSM-IVTR and eventually the DSM-V are *not* definitive- nor are they meant to be and should not be treated as such. Psychiatry and psychology as distinct fields of study are less than 150 years old (the modern era arguably beginning in earnest with Phineas Gage in 1848). Much of our outlook is based on centuries of philosophy, not science, because hard scientific data was lacking for so long. The scientific foundations of psychiatry and psychology are taking shape and growing an astonishing amount every year- hence the need for periodic revisions of the DSM.

One of the challenges for the DSM as well as for the fields of psychology and psychiatry is to balance reductionism against humanism. It is tempting to try to reduce mental disorders to genetics and biochemistry, but doing so misses much if not most of the power of human experience, of learning, of growth and development. And in doing so we risk devaluing the effects of choice, taking action and striving to make a difference in our own lives and the lives of others.

We know from other fields of study that genes are frequently not deterministic. Genes can be activated or deactivated by environmental factors, by stress or the removal of stress, etc. Finding intelligent and thoughtful ways to identify, describe and catalog mental disorders is a monumental challenge- to the extent that it is folly to expect the DSM to be definitive. The task is simply too enormous and complex and at this point in time we must be content with improvement and progress rather than perfection. Policies and decisions made based upon the DSM must bear these limitations in mind.

Posted by: Ilikemyprivacy | February 12, 2010 9:54 PM | Report abuse

Ilikemyprivacy, thanks for another informed and informative comment in this thread, taking up a position more akin to my layman's point of view than that Dr. Pies thought-provoking remarks.

Would that every Washington Post article produced such fascinating comments.

Posted by: douglaslbarber | February 12, 2010 10:18 PM | Report abuse

We need fewer diagnosis of depression and less antidepressant use.

The Physicians Desk Reference states that SSRI antidepressants and all antidepressants can cause mania, psychosis, abnormal thinking, paranoia, hostility, etc. These side effects can also appear during withdrawal. Also, these adverse reactions are not listed as Rare but are listed as either Frequent or Infrequent.

Go to www.SSRIstories.com where there are over 3,600 cases, with the full media article available, involving bizarre murders, suicides, school shootings/incidents [53 of these] and murder-suicides - all of which involve SSRI antidepressants like Prozac, Zoloft, Paxil, etc, . The media article usually tells which SSRI antidepressant the perpetrator was taking or had been using.

Posted by: Rosiecee | February 13, 2010 11:24 AM | Report abuse

This is a fine point but I don't believe that treatment is the end goal of psychiatry. Solutions should be the end goal.

Posted by: Fred25 | February 13, 2010 11:31 AM | Report abuse

The contradiction between the western medicine is the interpretation that a disease is just the biological or the biochemical structure of the human being. Human beings are more than molecules are cells, and part of the controversy in today diagnosis is the absent of spiritual dimension in the treatment of any mental disorder. Prescription alone is not the answer. To treat a patient, the professional should consider a holistic approach: the connection between body, mind and spirit. As long as the medical establishment is gear toward profit rather than wellness, the mental health of the american people will be attached to the big pharmaceutical corporations. We need to integrate balance into the system, otherwise, who cares about the DSMV has to say about mental disorder? Psychiatry is not a science and we are living in a society that is being ruled by special interests, opposed to the betterment of the human being.
Miguel A. Colon,PhD Holistic Health Practitioner, Phila, Pa.

Posted by: colon1927 | February 13, 2010 4:35 PM | Report abuse

Without a decent (bottoms-up) model of the brain and improved agreement regarding basic definitions (e.g., what we really mean by "abnormal" or "disease") I think we're kidding ourselves.

Katrina's unsupported assertion that we need a definitive and authoritative reference to alleviate pain and suffering just begs the question. Sure you do...but how do you GET one?

With respect to the practitioners who are desperately trying to turn their "centuries-old philosophy" into real science:

I suspect folks will look back on our era and conclude that psychiatry and psychology were approximately as effective in treating mental "disorders" as medieval barbers were in treating physical ones. And not much less barbaric.

Posted by: cynicalidealist | February 13, 2010 4:43 PM | Report abuse

This is a ridiculous article. Nobody is arguing that there should not be a DSM, not even its critics.

Ms. vanden Heuvel really needs to start thinking some thoughtful thoughts, and stop making embarrassingly facile observations like "critics should realize that an authoritative reference is an essential tool for alleviating the suffering of those who are afflicted" and "how, oh how, will the poor ever stop being obese when the price of a head of organic romaine lettuce is $3.49!", if she wants to maintain the tiniest shred of credibility.

Posted by: Itzajob | February 13, 2010 7:55 PM | Report abuse

I have returned to this article (and the reader comments) several time, and each time, I find more and more valuable information in the reader comments. I wish to especially thank rpies1 and likemyprivacy for their perceptive insights into the problem of standardizing psychiatric disorders.

I, personally, find myself caught between my intellectual being and my experience as a misdiagnosed psychological patient. My intellectual self would say that any attempts to standardize categories based on descriptive standards lacks scientific rigor. You can describe forever, but without rigorous definitions and some degree of quantitative measure, the final judgment about individuals is left up to the human abilities of the person doing the diagnosis. One psychiatrist may say that a person suffer from condition A, but there is no real standard that defines what condition A is that can be shared by other diagnosticians. The result, in reality, is that other diagnosticians rely on the original diagnosis, without any scientific basis for that judgment.

Secondly, another problem with purported standardized diagnosis has to deal with the goal of that activity. It seems that the goal of the DSM is to help insurance companies decide whether to pay for treatment and to help pharmaceutical companies decide whether to pursue the development of drugs that may or may not alleviate the symptoms of mental illness. I would, rather, the the goal of standardized diagnoses would be to alleviate the suffering of those who have mental illnesses. And I think that the research indicates that the use of pharmaceutical treatment, alone, is not the best of all treatment. Having worked in a mental health center, I am all too familiar with the lines of men and women, standing to receive their weekly (monthly, whatever) shot of whatever medication that hides the symptoms of their disease. No effort was made to help these people learn the strategies and tactics to deal with their illness. Instead of alleviating the personal suffering of these people, the psychiatrists used medication for the purposes of social control. This, to me, is a complete disregard for the well being of those who suffer.

Psychiatry has a long way to travel before they can say that they are doing anything to alleviate the suffering of those whose lives are impacted by mental illness. And offering descriptive categories in the name of science doesn't make the cut.

Posted by: marmac5 | February 14, 2010 1:09 PM | Report abuse

I would like to respond to two misconceptions about psychiatric diagnosis and treatment, with the caveat that a full discussion would require pages of data and elaboration.

The first misconception is that diagnosis in psychiatry and related fields is totally "subjective", and that one clinician rarely agrees with another on the patient's diagnosis. This is usually contrasted with supposedly "objective" disciplines such as chemistry or physics, or with certain medical specialties, such as pathology.

The second misconception is that psychiatry and related fields really have no effective treatments, and that such treatments that exist are merely directed at controlling disapproved of behaviors--this is the legacy of the "anti-psychiatry" movement that began in the mid 1960s and continues to this day.

Both these notions are simplistic and wrong-headed; neither is supported by the available evidence. First: there is as much "objectivity" in psychiatric diagnosis as there is in many diagnoses made by, say, neurologists, when they diagnose "migraine headache", or by rheumatologists when they diagnose "fibromyalgia" (there are no "lab tests" for either migraine or fibromyalgia). Second: inter-rater reliability for psychiatric diagnoses (the ability of two diagnosticians to agree on the diagnosis) is as high for several psychiatric diagnoses as it is for many in general medicine.

The notion that psychiatric treatments are not effective is belied by a government report done in 1993, showing that psychiatric treatments are, on average, as effective as many in cardiology or general medicine. There are no data to this date that overturn this conclusion.

Though treatments in psychiatry are far from ideal, and do have significant risks associated with them, they are at least as safe and effective as many treatments for heart disease, cancer, and other serious illnesses. We understand that cancer is a potentially fatal illness, and that chemotherapy, even if effective, may have serious side effects. Yet we don't apply the same reasoning to major depression, which carries with it a 15% mortality rate (almost entirely from suicide) if left untreated. Yet we do have effective treatments for depression, and I am not speaking only of medications. Contrary to a popular notion that psychiatrists don't provide psychotherapy anymore, many of us still do! And psychotherapy can be a very effective treatment for many patients with depression, anxiety and related conditions.

Much, much more could be said: but I would urge readers to take a look at two articles dealing with these issues in detail. The web addresses follow. Thanks for your patience and willingness to consider the other side of the debate--Sincerely, Ronald Pies MD

http://www.psychiatrymmc.com/how-%E2%80%9Cobjective%E2%80%9D-are-psychiatric-diagnoses-guess-again/

http://www.psychiatrictimes.com/display/article/10168/1518165?verify=0

Posted by: rpies1 | February 14, 2010 2:44 PM | Report abuse

[Warning: this is not a "bumper sticker" response; it is in two parts, and
it will take some patience,so thanks!]

I appreciate the thoughtful questions from Douglas Barber, and also the comments from likemyprivacy, with which I am broadly in agreement.

Before venturing a response to Mr. Barber, I'd like to clarify a few points re: the DSM-5; theories of "mental illness"; and the
field of psychiatry as a whole.

It is easy (and, evidently, very popular) to conflate the nature and purposes of the DSMs with those of so-called "biological psychiatry", "Big Pharma", or the field of
psychiatry as a whole. This is an error, in my view.

First, the DSM-5 is not intended to present a comprehensive theory of mental illness, or to "take sides" in the eternal (and largely sterile) debate between "biological" and
"psychological" (or cultural) theories of mental illness. It is both a strength and weakness of the DSMs that they have not embraced a comprehensive theory of how mental illnesses arise and why they are maintained.

Nor is the DSM-5 a "treatment manual" that tells practitioners to prescribe medication, provide psychotherapy,exercise, etc. (I know that conspiracy theorists love to imagine that all
the framers of the DSM-5 are in cahoots with drug companies, and shape diagnoses in order to increase drug sales. What can I say? No evidence to the contrary is likely to persuade these individuals. Suffice to say
that a diagnosis of major depressive disorder, or anything else, in DSM-5 does not tell a practitioner what treatment is most appropriate).

It is also a mistake to paint the entire field of psychiatry with the brush of "biological" or genetic theories of mental illness. No
psychiatrist of any sophistication believes that mental illness is solely the result of a "chemical imbalance"!

The most common model among psychiatrists is the "biopsychosocial" model, originated by Dr. George Engel. This sees psychiatric illness
as the outcome of biogenetic, psychological, social, and cultural "inputs". The brain, in a sense, is the "funnel" into which all these factors are "poured."

In light of this, most psychiatrists believe in a comprehensive approach to treatment, that involves biological, psychological, social, and even spiritual approaches to the patient's needs. Unfortunately, "market forces"
and other factors have greatly limited the psychiatrist's ability to provide such holistic care...but that's another story.

End part I

Posted by: rpies1 | February 14, 2010 3:09 PM | Report abuse

R. Pies MD --Part II

Finally,to Mr. Barber's question re: culturally specific diagnoses.

First, Mr. Barber, I'd like to say that the major and most serious psychiatric disorders--schizophrenia, bipolar disorder, and major
depression--are not very culturally-specific, and, in fact, are relatively uniform in both prevalence and symptom picture throughout
the world.

I emphasize "relatively", since there are certainly variations from country to country. I am also aware of the arguments put forth by Ethan Watters in the Sunday (1/10/10) New York Times Magazine, in which he argues that we
have imposed "Americanized" psychiatric diagnoses on native cultures.

It is true that there are "cultural variant" syndromes--such as Koro, Piblokto, Amok, and other rare conditions--that do seem culturally-specific; but I believe most of these are variants of psychotic or affective disorders
that we recognize in the West.

Is it possible that "...some of these cases are indeed disorders that arise at the level of operations of thought, with no corresponding
biological substrate that's any different than a "normal" one?"

Yes, it is certainly possible, Mr. Barber, but some philosophers of mind would argue (and I would agree) that there is no "operation
of thought" that does not have a "biological substrate." That is, every operation of what we call "mind" is a process of the brain.

But you are quite right in suggesting that we might not detect any gross "brain abnormality" in a person experiencing, say, the "ataque", which is a culturally-sanctioned "cry for help" seen in some Latin American countries. That is, there may be nothing structurally or functionally "wrong" with the person's brain that would show up on a CAT scan, MRI or EEG; in that sense, one could say that the behavior (falling to the ground, screaming, etc.) is indeed mediated by the person's thoughts and emotions, as shaped by the ambient culture.

My point in my original note was to suggest that for the major mental disorders, it is useful to locate biological markers, if possible. That aids in making more secure diagnoses, and in devising treatment
approaches. It does not necessarily point to the "cause" or etiology of the condition. To give just one example: we have good evidence that in schizophrenia, a sub-type showing enlarged cerebral ventricles (fluid-filled cavities) is associated with a poorer prognosis and decreased response to medication.

If you are still conscious after this long, long response, Mr. Barber, I'll suggest checking out two articles that may be of interest. The web addresses follow. Thanks for your interest and patience, in an age of
"tweets" and sound-bites!

Sincerely, Ronald Pies MD

http://www.psychiatrictimes.com/display/article/10168/1402032

http://www.psychiatrymmc.com/beyond-reliability-biomarkers-and-validity-in-psychiatry/

Posted by: rpies1 | February 14, 2010 3:12 PM | Report abuse

a few years ago, several psychiatrists evaluated psychiatric case histories and reached concensus as to the diagnosis of each case history. they then sent it out to psychiatrist across the United States asking for diagnosis based upon the case hisory. 1500 psychiatrists responded. there was less than 10% agreement as to the diagnosis. diagnosis is a way to bill insurance and medicaid and helps a dcotor justify which medication to use. i was diagnosed as having paranoid schizophrenia, which turned out to be major depression with anxiety. i was told i would be on thorazine, stellazine, and cogentin for life. i've been medication free for 15 years now. imagine that. by the way several cultures don't use diagnosis and do a pretty good job at treatment. then too, in two 17 year longitudinal studies by the WHO, there are 3rd world countries having better treatment outcomes for mental illness than the United States. Keep your DSM, just another way to legitmize a hocus pocus business.

Posted by: mhalligan83 | February 15, 2010 9:58 AM | Report abuse

There continues to be a tremendous social stigma against people who suffer from mental illnesses. Plenty of blame and shame is directed at those who do, along with their professional caregivers, whether it's a psychiatrist, psychotherapist or both. The DSM manual is needed so there is uniformity in diagnoses and let's face it, insurance companies require the diagnostic coding for billing purposes. I find it ridiculous that anyone would question the need for a diagnostic manual for psychiatric and mental disorders. If we were talking about physical medical problems, this discussion likely would not be taking place. Psychiatry isn't an exact science, but neither is any other type of medical practice. Mental illnesses are legitimate medical problems just like heart disease and cancer are medical problems.

Posted by: RuralVermont | February 15, 2010 5:31 PM | Report abuse

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