"My dear Sir, take any road, you can't go amiss. The whole state is one vast insane asylum."
— James L. Petigru
Spend just a few minutes watching prime time television with its endless pageant of commercials for antidepressants and anti-anxiety meds and you start to wonder if USA really means the United States of Affliction.
Such "direct to consumer" drug advertising ties into one of the most far-reaching criticisms in revising the Diagnostic and Statistical Manual of Mental Disorders: the potential to transform normal human behavior into a mental disorder.
This issue didn't arise with the ongoing revision of the DMS-V. It's long been a concern for psychiatry, which must exist uneasily alongside pharmaceutical companies' hopes of expanding their markets and Americans' desire for take-a-pill quick fixes. But past experiences suggest new diagnoses will reap a harvest of not fully intended consequences of patients larded with labels — and prescriptions.
Christopher Lane, an intellectual historian who has written extensively on psychiatry and culture, detailed the inclusion of "social anxiety disorder" in the DSM-III in his 2007 book, Shyness: How Normal Behavior Became a Sickness.
Lane revealed how the 15-member DSM-III task force, in its quest to establish psychiatry as a legitimate science (and riding the wave of drug companies looking to expand their markets for anti-psychotics and tranquilizers), spit out "almost over night" various new disorders, including one for those uncomfortable with social situations.
A series from Miller-McCune.com on the controversy surrounding the latest Diagnostic and Statistical Manual of Mental Disorders:
Part I:Infallibility and Psychiatry's Bible (May 25)
Part II:Who Benefits? DSM Conflict of Interests (June 3)
Part III: Are You Normal or Finally Diagnosed? (June 8 )
No longer need shyness be a variant of normal. Now it can be a neurochemical disorder addressable with GlaxoSmithKline's multibillion-dollar marvel Paxil. Before safety concerns and patent expirations raised their ugly heads, antidepressants had become the second-largest selling class of drugs in the United States.
"In this desire to biologize and medicalize, with the idea that every personal crisis or problem is due to a disorder of the brain, we've lost sight of the vast complexity of behavioral responses to external stresses," Lane says. Add to that some possibly dangerous side effects. Along with Prozac and Zoloft, Paxil was found to increase thoughts of suicide, especially among teens, prompting an FDA warning in 2004.
The concern about medication also extends to the proposed "minor cognitive disorder."
One of the "19 worst suggestions" for reformulating the DSM, according to Allen Frances, whose brush war with the revisers was the subject of the first story in this series, would be to pathologize reduced cognitive performance — like forgetting why you walked into the kitchen, something very common in people over 50. "The threshold has been set to include a whopping 13.5 percent of the population ... which will result in much unnecessary treatment with ineffective prescription drugs and quack folk remedies," Frances says.
But Darrel Regier, the vice chair of the DSM-V task force and executive director of the American Psychiatric Institute for Research and Education, says being able to differentiate between a normal aging brain and what's pathological is a huge public health issue.
"All of medicine is trying to figure out how do we know and when do we know it, in terms of our ability to either intervene early or prevent. To challenge that is just nonsense!" he says.
Lane, however, insists that what the APA is doing amounts to mere "guesswork." He sees a similar problem with the proposed "binge eating disorder." In an attempt to differentiate the estimated 3.5 percent of U.S. women and 2 percent of men who occasionally gorge themselves, from those who simply overeat, Lane says the DSM-V is attempting to transform a fuzzy analysis into a clear-cut distinction. Plus, binge eating can be a response to overwhelming personal events like a cancer prognosis.
"When someone receives such a diagnosis, their likelihood of binge eating for weeks at a time increases dramatically due to completely understandable anxiety and fear. If the APA were to proceed with a DSM diagnosis for binge eating, they would be sweeping up all such people within the nets of the mentally ill," Lane says.
Frances warns that such a diagnosis will stigmatize the tens of millions of people who binge eat once a week for three months.
Regier, though, says "the changes in criteria are not going to make a whole lot of difference in who comes in for treatment."
Regier is referring to the widely anticipated incorporation of the "dimensional model" for characterizing a patient's symptoms. Previous DSM's have employed what Lane calls a "rather clumsy five-out-of-eight criteria" checklist. As the DSM-V website says, "While these specific criteria for disorders were a vast improvement over the previous diagnostic guidelines available to diagnose patients with mental disorders, there are real-world problems with this system of diagnosis."
Now, "dimensional assessments" would let clinicians measure a wide range of symptoms that "cross cut" across a variety of disorders, noting both their presence and their severity.
"For instance," to again quote the DSM-V website, "information about depressed mood, anxiety level, sleep quality and substance use would be important for clinicians to know regardless of the patient's diagnosis. Dimensional assessments would allow clinicians to rate both the presence and the severity of the symptoms, such as 'very severe,' 'severe,' 'moderate' or 'mild.' This rating could also be done to track a patient's progress on treatment, allowing a way to note improvements even if the symptoms don't disappear entirely. It would encourage mental health professionals to document all of a patient's symptoms and not just those that were tied to their primary diagnosis."
Unfortunately, this technique has not been proven and is likely to prove exceedingly complex.
Complexity, meanwhile, appears absent in one of the more chastised new proposals: "hyper sexuality disorder." Consider the first criteria: "A great deal of time is consumed by sexual fantasies and urges and by planning for and engaging in sexual behavior."
Lane says: "That's proposed language for DSM-V, 'a great deal of time!' This is a scientific manual. At what point is the APA trying to establish how much sex falls within the realm of the acceptable? I find it very disturbing that they would even contemplate some kind of working definition of what constitutes normal sexual desire. They're setting themselves up as judge and jury on this."
Similar problems exist with what Frances calls "one of the most dangerous and poorly conceived suggestions" for DSM-V, Temper Dysfunctional Disorder with Dysphoria. It will be, he says, "a misguided medicalization of temper outbursts."
TDD is actually intended to correct the crisis of over diagnosis (an increase of 8,000 percent over a decade) of childhood bipolar disorder. Frances says that to avoid misidentifying children with a lifetime diagnosis, the Childhood Disorders Work Group created a diagnosis that is more "state-related," or short term.
"The problem I'm afraid is that it will go the other way. Kids who have more normal type temper tantrums will be diagnosed with this and many may also get meds that have harmful side effects and complications."
But Regier insists that TDD is not a routine temper tantrum. "Human beings have a limited repertoire of how they express emotion. And when temper reaches an extreme, we're talking about a temper dysregulation disorder," he says.
Daniel Carlat, who edits the peer-reviewed Carlat Psychiatry Report (which proudly notes it receives no pharmaceutical industry funding) disputes the critique that the DSM pathologizes human behavior.
"People without any pathology who are normal, who are simply responding in a normal and understandable way to life events are typically not even going to be seen by a psychiatrist. If they're seen by anybody, it'll be a therapist and they'll be able to talk out their issues and won't be put on medication — except maybe a sleeping pill or something mild from their primary care doctor."
As Carlat writes in his new book, Unhinged: The Trouble with Psychiatry — A Doctor's Revelations about a Profession in Crisis, "the DSM has not created pathology where it does not exist.
"But it has done something almost as harmful. It has drained the color out of the way we understand and treat our patients. It has de-emphasized psychological-mindedness, and replaced it with the illusion that we understand our patients when all we are doing is assigning them labels."
The disputes surrounding the DSM can be dizzying, fueling the belief that psychiatry is far from becoming a science. After all, despite meteoric advances in understanding brain chemistry over the last decade, there still are no specific chemical or medical tests to validate any mental disorder.
That said, the controversies presented here center around suggestions contained within a draft document. Three years and much discussion and analysis remain before the proposals are finalized. And even if the most controversial ones end up in the DSM-V, for all the talk about the DSM as gospel, Carlat reminds that the DSM-V is "no more than an elaborate and hopefully accurate list of disorders and diseases."