Tuesday, 17 April 2012

DSM: The Bible of Mental Illness

The Beleaguered DSM: a love story with consistency and classification
The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been hailed as the ‘mental health bible’ for psychiatrists and other clinicians. It is used to diagnose mental health disorders such as depression, anxiety, ADHD, schizophrenia, bipolar disorder, autism, among many lesser-known maladies of the mind. The DSM is updated periodically, inevitably along with an increase in the number of diagnosable disorders
(see table). It has been dogged by criticism since its conception but has also served as a reflection of changing times; in 1980 DSM-III listed homosexuality as a mental disorder.

Good Intentions
Although collated and published by the American Psychological Association, the DSM is also used, or at least referred to, in the UK. Conceptually, it is wonderful; an all-encompassing one-stop-shop for clinicians to consistently diagnose mental health disorders...right? As Michael Conner [1] puts it, ‘the mere fact that any diagnostic system is reliable does not mean the process is valid, useful and not harmful.’ One particular sample of mental health patients found that diagnoses of schizophrenia ranged from 163 to 19 cases, depending on the interpretation of the diagnostic criteria used.

Conner sees mental health diagnostic processes as no less sophisticated than those used to diagnose headaches or inner ear problems. He distances subjective psychological problems from hard-nosed, matter-of-fact medical diagnoses of, say, cancer, wherein objective variations in biochemistry become arbiters of diagnosis instead. The premise is that subjective diagnosis, by definition, cannot be scientific and as a result the concept of consistency in psychiatry is flawed.

Publication Date
Major diagnostic categories
Possible Diagnoses

One need only look at the table above to recognise that they didn’t get it right first time. In fact, the biggest increase of possible diagnoses was between DSM-I and II. Post-WWII America was discovering its sensitive side by spending more time on the psychiatrist's couch. I think there is no doubt that history and culture played a part in fleshing out the DSM - what were doctors supposed to do with all those shellshock sufferers?

An Example
Before we move on, it may be useful to look at an example of how the DSM defines disorders. I have chosen diagnostic criteria for a Major Depressive Episode (depression). You needn’t read it all, but it’s just to give an idea of the layout and kind of information provided:

Diagnostic criteria for Major Depressive Episode

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either:

  • (1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). 
  • (2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) 
  • (3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.  
  • (4) Insomnia or Hypersomnia nearly every day 
  • (5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) 
  • (6) fatigue or loss of energy nearly every day 
  • (7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) 
  • (8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) 
  • (9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide 

Taken from DSM-IV.

The Latest Addition to the Family
According to an FAQ on the specially set-up DSM-5 website [2], new technologies (primarily fMRI) and intensive research mean that the Bible must be updated. Surely no one would argue with this; it would be preposterous to ignore the tasty fruits of contemporary research. However, some have highlighted links between DSM-contributors and the pharmaceutical industry [3],[4] . Is the number of diagnoses being tampered with in order to deepen pockets? More possible disorders equates to a wider range of drugs to treat them, right? I am sceptical of this claim – they are clinicians after all, and wouldn't you be worried if they didn't have any links to the industry that bases its products on their research?

Further enquiry reveals that DSM-5 (which is getting rid of Roman numerals to be down with the kids), has been in pre-planning talks since the beginning of the 21st century. Even previous revisions were taken into deep consideration, being published 7 and 6 years respectively after their progenitors (I refer to DSM-III, DSM-III-R, etc). According to the website, “work groups (made up of global experts in various areas of diagnosis) have looked at what elements of the current edition (DSM-IV) are working well, what elements do not meet the needs of clinicians and how best to correct those concerns.” So at least they're trying.

Some recent recommended amendments include the collapsing of Autism, Asperger’s, Pervasive Developmental Disorder, and Childhood Disintegrative Disorder into one ‘overarching category of ASD [Autism Spectrum Disorder][5], as well as the reduction of personality types to six, including: antisocial, avoidant, borderline, narcissistic, obsessive/compulsive and schizotypal. “In the past, we viewed personality disorders as binary”, says Dr. Andrew Skodol[6]. “You either had one or you didn’t. But we now understand that personality pathology is a matter of degree.” The Personality Disorders Work Group advocates a more dimensional approach, as opposed to a categorical one: as Dr. Skodol says, this kind of thing simply isn’t black or white as patients may exhibit characteristics that straddle boundaries.

Medicalising Normality
Chair of the DSM-IV task force and staunch opponent of the latest edition, Dr. Allen Frances has voiced his concerns that DSM-5 will “medicalise normality”[7]. He alludes to the over-diagnosis of ADHD (something I will blog about separately at a later date), ‘false epidemics’ of binge-eating and hypersexuality, and over-prescription of antipsychotic medication. In Psychology Today [8], he blames fads for apparent surges in overdiagnosis, but who is guilty of giving into the fad? Surely he must mean the psychiatrists themselves, since they are the ones who are doing the diagnosing. And is it never acceptable that certain conditions may be more prevalent today than previously?

Perhaps Frances' reaction is bitter and antagonistic since losing his former level of authority and control with the previous edition. Dyslexia was once scorned and laughed at as a pseudo-disorder. Today it is (pretty much) widely accepted by the psychological community of clinicians and researchers as a legitimate disorder, for which support is available. Dyscalculia, a congenital condition in which leaves the individual without a ‘basic feel for number’, is "rather where dyslexia was thirty years ago"[9]. In other words, its existence is disputed, although it is listed in DSM-IV as 'mathematics disorder'.

A disorder is simply a label for a specific set of symptoms or characteristics. Unfortunately we’re all too aware of what can happen to labels, namely negative associations and inappropriate use. I have heard people complaining – yes, complaining – that the label ‘dyslexia’ used to be commonly known as ‘stupidity’. People bemoan the fact that they have one less way to offend others who would formally have been openly subject to another label: stupid. While we’re at it, dyslexia bears no correlation with intelligence.

My stance is that advances in diagnostic tools and research have allowed us to investigate the previously arcane and clandestine workings of the mind. A lot of time and resources have been poured into researching cognitive faculties of people who struggle with numeracy. The result has been the classification of a new disorder.

What is a disorder? It's a pattern (of behaviour) that is not considered part of normal development. In 1980 it was argued that homosexuality was indeed within normal development and variation, much to the chagrin of DSM-III authors. But here's the thing - homosexuality is not a disability. It doesn't represent a deficit in functioning or some kind of problem to be overcome. The point I'm trying to make is that a set of behaviours can and should be termed a 'disorder' if it negatively affects the individual's life.

So what's wrong with those 'false epidemics' of binge-eating and hypersexuality? Why is Frances so resistant? If we, as psychologists and fellow compassionate humans, can do anything to help these individuals, why would we deny them this?

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