Normal one day, mentally ill the next

If you don’t have a mental illness now, you may have one soon . . .

The American Psychiatric Association (APA) publishes a catalogue of mental illness called the Diagnostic and Statistical Manual of Mental Disorders (DSM). It provides detailed checklists of symptoms for each disease (“A patient can be diagnosed with such-and-such if the patient has at least 3 of the following 17 symptoms on most days for at least 6 months, or 8 symptoms for at least 3 months, or 2 major and 6 minor symptoms for most days for at least 6 weeks. . .”).  The idea is to add consistency to psychiatric diagnosis: any two clinicians using the checklists of the DSM to evaluate a patient are supposed to be able to come up with the same diagnosis. So, a bunch of doctors at the APA get together and decide what qualifies for a mental illness and its symptoms. If you think about the stigma and the social and financial repercussions that come with a psychiatric diagnosis, you can see how important and powerful this one little book can be.

The DSM was originally published in 1952, enumerating 106 mental disorders in 130 pages. It has subsequently been revised; the current version is the fourth major revision, or DSM-IV, comprising 297 disorders in 886 pages. The APA is currently working on DSM-V, due to be published next year.

DSM-V has come under scathing attack, not least from the chairman of the DSM-IV task force. The reasons are many: the reductionism, the materialist assumptions, the arbitrary criteria, the sums of money the APA makes off of the DSM, the field trials that were a sham; but one of the more worrisome to me is the lowering of diagnostic thresholds for many disorders, which will lead to a greatly increased rate of mental disease in the general population and further promote the medicalization of many conditions previously seen as normal; and that much of this may be driven by pharmaceutical companies who sell the drugs that “treat” these conditions. This eagerness to give people diagnoses so that medications can be prescribed for them is nothing new; I remember in the 1990’s that when the first medication received FDA approval to treat “Social Anxiety Disorder” (SAD), I was suddenly inundated with invitations to talks and symposia whose purpose was to convince me that I had lots of people with SAD in my practice that would benefit greatly if I were to diagnose them and prescribe this medication.

So, DSM-V is coming. And with the lowering of the diagnostic bar for many mental illnesses, many of us might suddenly find ourselves diagnosably mentally ill. Which means we might suddenly qualify for expensive medications to treat our new mental illness. I can’t put it any better than Allen Frances, Professor Emeritus of Duke University and chairman of the DSM-IV task force: “A diagnostic system that affects so many crucial decisions in our society cannot be left to a small professional association whose work is profit driven, lacking in scientific integrity, and insensitive to public weal.”

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Jeremy Recent comment authors
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Very interesting notes about the DSM. I will have to keep my eye out for the DSM-V. Thanks!