Tuesday, June 11, 2013

Mental Disorders Proliferate in Newly Expanded "Bible" of Diagnoses

If you've ever wondered if you've got a bona fide psychological "disorder," the new handbook for mental health providers, the Diagnostic and Statistical Manual of Mental Disorders, Volume 5 has the answer--and it's more likely than ever to be "yes." The list of definitions was first published in 1952 as a spiral pamphlet describing eleven categories of mental disorder. Subsequent volumes (1968, 1973, 1980, 1994) ballooned the number of ailments, and now the 947-page tome boasts nearly 400 maladies. Sounds like the US tax code (73,608 pages).
Like lawmakers who keep writing more laws, and the IRS, that keeps writing tax regulations, psychiatrists just can't stop defining who's sick. Of course, that's what they're all paid to do, and the ones who want to keep their jobs are invested in adding to the density of their fields. A politician gets famous and re-elected for creating landmark legislation. The IRS hires more people as citizens might be violating more rules. But psychiatrists?

Same thing, especially the way health care payments are evolving under Obamacare, set to cover 32 million Americans who never before enjoyed this benefit. As descriptions of disorder include more people, mental health professionals' clientele and reimbursements grow.
A cynical view, maybe, but it's undeniable that a growing number of people now have a diagnosis to pin to their conditions. A review of the new psychiatric tome by Dr. Carol Tavris in the New York Times sheds light on what's going on.

As part of her look at the new "Bible" of mental ailments, she considers Gary Greenberg's bash, The Book of Woe. Greenberg doubts the entire enterprise of labeling clusters of symptoms. The new DSM-5 supposedly used ethical, empirical trials to verify that its categories are discrete, or at minimum that professionals would agree on diagnoses. Greenberg exposes the fallacy in all that, and says the American Psychiatric Association rushed to publication without adequate reliability testing because it desperately needed the money from its sale.
The new DSM tries to describe disorders so prescribers can choose appropriate medications. But even though more people than ever take pills to moderate feelings and behaviors, nobody's ever seen brain markers for specific illnesses, and as Dr. Tavris notes, "no lab tests yet exist for depression, schizophrenia, bipolar or obsessive-compulsive disorder, or, for that matter, any other mental disorders."

But plenty of professionals dismiss the touchy-feely aspect of therapy, and prefer nice, neat medical definitions, just like other illnesses have. The taxpayer-supported National Institute of Mental Health is spending our money basing a new competitor volume to the DSM-5 on exactly that idea, according to director Thomas Insel: "Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion or behavior." That one should be a really fun read.
But there has to be a middle road--don't some disorders have emotional or situational roots, while others are malfunctions of brain circuitry? It's also not an either-or thing--many disorders are combinations of both--and the proportions of physiological versus mental components in a single person's disorder can fluctuate. We just don't know enough about the mind-body connection to get haughty.
But docs are haughty enough to load the Psychiatric Association's manual with so many disorders that any creative or idiosyncratic person can surely find herself somewhere in its pages. Allen Frances, editor of the previous edition of the DSM, knocks the current volume (in his own new book, Saving Normal) for "new diagnoses that would turn everyday anxiety, eccentricity, forgetting and bad eating habits into mental disorders." Dr. Tavris responds that Frances' own DSM-4 "gave us a Disorder of Written Expression, Caffeine-Induced Sleep Disorder and Age-related Cognitive Decline, all of which I suffer on every deadline." Beneficiaries of Obamacare take note: you can be eligible for treatment as a result of normal living.
We need to see both individuals and diagnostic categories as fluid and changeable, especially since psychiatry is such an inexact science, but instead, we wrap our identities around them. But where does that leave the likes of me--a psychologist and not a psychiatrist? This is an issue I haven't seen discussed: that psychiatrists, those med-school-trained prescribers of pills that alter brain chemistry, wrote the book for the rest of us therapists, the ones whose best and only weapon is talk.

I see therapy as educating clients about patterns that keep them in nonconstructive habits, and suggesting personalized alternatives that allow them to reach their goals. Great for problems where the client can control his feelings or the situation, but what of the person whose anxiety comes unpredictably, or whose overwhelming compulsions have no logical basis?

I'm with the NIMH in seeing that brain chemical-altering medications can greatly improve not only serious disorders like schizophrenia, but many of the "neuroses" that we previously ascribed to volition. There's probably no way to know what part of behavior is physiologically/neurologically/hormonally caused and not really under a person's control, versus what part is psychological and attitudinal. Increasingly, researchers are finding that the physiological plays a dominant role in disorders.
Even if medication is likely to work, prescribing is an art, not a science, often a hit-or-miss dance where symptoms recede and return. The same medication may alleviate symptoms for one person and exacerbate them in another, even when both seem to have the same problem. Or the dosage or manufacturer may be the critical variable, and in any case, hitting the medication sweet spot with minimal side effects and maximized benefits is a personalized journey of trial-and-error.

That leaves the question of the usefulness of the DSM-5. With so many political, social and financial ramifications, collecting symptoms into diagnoses is fraught with peril.
To offer a controversial example: Plenty of people (gays included) continue to suffer from being homosexual or belief that it's deviant, even though it was deleted as a disorder two Manual editions ago. The justification for the cut would be that the diagnosis itself created suffering, and that once homosexuality is fully accepted, gays can be at ease with their orientations. But if that's the case, then expanding the number and scope of disorders, as the new Manual does, increases our nation's woe.

But somebody's gotta put names to what's ailing the populace. I have a friend whose 25-year-old daughter lives with Asperger's Syndrome. When the girl was growing up, before her problem was identified, the mom faced a frustrating and heart-wrenching task finding the right school for her. The girl "bounced off the walls," acted inappropriately, and couldn't follow through on anything. Once she was diagnosed with Asperger's Syndrome, the family could finally make sense of her symptoms and stopped blaming themselves. This allowed them to better shape their expectations of her, and more confidently approach sources of help.

So slotting symptoms into diagnoses offers both benefits and drawbacks. Sometimes, though, individuals slide through the slots onto a conveyor belt to certain standard treatments--when the patients would be better off as a unique sum of their particular assets and issues. As we learn more about the mind, what we discover is that its workings are more complex than we thought, not less. Its foibles become less likely to fit into defined parameters, and become more defiant of labeling--just as we're locking down those very labels in authoritative "bibles."
Mental health professions should heed Dr. Tavris' suggestion for responding to the revered tome: "If people treated the DSM the way most treat the other Bible--nod their heads to it, say they believe in it, and continue sinning--we might be all right."

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