Psychiatrists Revise the Book of Human Troubles
By Benedict Carey
December 18, 2008
The book is at least three years away from publication, but it is already stirring bitter debates over a new set of possible psychiatric disorders. Is compulsive shopping a mental problem? Do children who continually recoil from sights and sounds suffer from sensory problems — or just need extra attention? Should a fetish be considered a mental disorder, as many now are?
New Definition of Autism Will Exclude Many, Study Suggests
By Benedict Carey
January 19, 2012
Proposed changes in the definition of autism would sharply reduce the skyrocketing rate at which the disorder is diagnosed and might make it harder for many people who would no longer meet the criteria to get health, educational and social services, a new analysis suggests. The definition is now being reassessed by an expert panel appointed by the American Psychiatric Association, which is completing work on the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders, the first major revision in 17 years. The D.S.M., as the manual is known, is the standard reference for mental disorders, driving research, treatment and insurance decisions. Most experts expect that the new manual will narrow the criteria for autism; the question is how sharply. The results of the new analysis are preliminary, but they offer the most drastic estimate of how tightening the criteria for autism could affect the rate of diagnosis. For years, many experts have privately contended that the vagueness of the current criteria for autism and related disorders like Asperger syndrome was contributing to the increase in the rate of diagnoses — which has ballooned to one child in 100, according to some estimates.
Grief Could Join List of Disorders
By Benedict Carey
January 24, 2012
When does a broken heart become a diagnosis? In a bitter skirmish over the definition of depression, a new report contends that a proposed change to the diagnosis would characterize grieving as a disorder and greatly increase the number of people treated for it. The new report, by psychiatric researchers from Columbia and New York Universities, argues that the current definition of depression — which excludes bereavement, the usual grieving after the loss of a loved one — is far more accurate. If the “bereavement exclusion” is eliminated, they say, “there is the potential for considerable false-positive diagnosis and unnecessary treatment of grief-stricken persons.” Drugs for depression can have side effects, including low sex drive and sleeping problems. But experts who support the new definition say sometimes grieving people need help. “Depression can and does occur in the wake of bereavement, it can be severe and debilitating, and calling it by any other name is doing a disservice to people who may require more careful attention,” said Dr. Sidney Zisook, a psychiatrist at the University of California, San Diego.
Not Diseases, but Categories of Suffering
By Gary Greenberg
January 29, 2012
…The D.S.M. is the offspring of odd bedfellows: the medical industry, with its focus on germs and other biochemical causes of disease, and psychoanalysis, the now-largely-discredited discipline that attributes our psychological suffering to our individual and collective history….The American Psychiatric Association has been…leaving behind ideas about the meaning of our suffering in favor of observation and treatment of its symptoms. In 1980, it hit on the strategy of adopting a medical rhetoric, organizing those symptoms into neat disease categories and checklists of precisely described criteria and publishing them in the hefty — and, according to its chief author, “very scientific-looking” — D.S.M.-III.
But as all those Diagnostic and Statistical Manuals have stated clearly in their introductions, while the book seems to name the mental illnesses found in nature, it actually makes “no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or no mental disorder.” And as any psychiatrist involved in the making of the D.S.M. will freely tell you, the disorders listed in the book are not “real diseases,” at least not like measles or hepatitis. Instead, they are useful constructs that capture the ways that people commonly suffer….
DSM-III AND THE REVOLUTION IN THE CLASSIFICATION OF MENTAL ILLNESS
Rick Mayes and Allan V. Horwitz
Journal of the History of the Behavioral Sciences Summer 2005
… With the DSM-III, biomedical investigators replaced clinicians as the most influential voices in the field. Even though few of those involved in Spitzer’s task force were associated with work on psychopharmacology or the biology of mental disorders, the biological default in what they proposed came about as one of the assumptions of neo- Kraepelinians—that the core symptoms of mental disorders stemmed from some form of brain malfunctioning. Consequently, psychotherapy became the primary domain of clinical psychologists, counselors, and social workers, who appeared to practice it as effectively as psychiatrists but who charged less. Psychopharmacological therapy became the private “turf ”of medically trained psychiatrists.
The publication of the DSM-III in 1980 caused a revolution in psychiatry. It also triggered a paradigm shift in how society came to view mental health. Prior to the DSM-III, psychiatrists primarily targeted the underlying psychological causes of mental illness and disorder with psychotherapy. Alternative approaches, such as behavioral therapy, were subordinated to the dominance of psychodynamic theory and practice. With the DSM-III, they gradually shifted to primarily targeting the symptoms of mental illness and disorder with psychopharmacology, the use of drugs to treat mental ills. The direct and indirect institutional change the new manual produced extended far beyond psychiatry, because the DSM is used by clinicians, the courts, researchers, insurance companies, managed care organizations, and the government (NIMH, FDA, Medicaid, Medicare). As a classificatory scheme, it categorizes people as normal or disabled, healthy or sick. And as the definitive manual for measuring and defining illness and disorders, it operates as mental health care’s official language for clinical research, financial reimbursement, and professional expertise. Few professional documents compare to the DSM in terms of affecting the welfare of so many people.
The DSM-III’s creation was not the result of a carefully orchestrated conspiracy, but neither was it an accident or “chance-like sequence” of events as some have argued. It did not stem from any new knowledge about the causes of mental illnesses nor their treatments. In addition, it did not enlarge the realm of behaviors that the psychiatric profession was to treat. Instead, its symptom-based focus stemmed from the efforts of research-oriented psychiatrists who wanted to standardize diagnostic criteria and focus attention on the symptoms of mental disorders, rather than on their underlying causes…
The struggle over the drafting and publication of the DSM-III appeared to be a clinical debate among psychiatrists, but underlying it all was a vehement political struggle for professional status and direction. “DSM-III is a political document in many ways,” observed Gerald Klerman. “It appeared in response to some of the ideological and theoretical tensions within the profession of psychiatry. It also has been caught up in the rivalries and tensions among the various mental health professions—psychiatrists, social work, psychology”.
Finally, while the DSM-III standardized the diagnostic classification scheme for mental illnesses and disorders, it did not include treatment guidelines. By virtue of its Kraepelinian orientation, however, it allowed pharmaceutical companies to market their products for a growing number of specific, symptom-based disease entities. The DSM-III unintentionally positioned psychopharmacology on a growth trajectory that various institutions—insurance companies, managed care organizations, pharmaceutical companies, and the government—propelled significantly in subsequent years as they responded to the DSM-III’s new diagnostic guidelines and the research incentives that it fostered.