DSM V and the Diagnosing of Human Behavior

http://www.psychiatrictimes.com/display/article/10168/1425378?pageNumber=4

A recent story in U.S. News and World Report states, "The Diagnostic and Statistical Manual of Mental Disorders, as it is known, is hugely influential because it determines what is and is not a mental disorder. In turn, it is responsible for much of the sales growth in prescription drugs."  In a recent article in Psychiatric Times Dr. Allen Frances discusses his concerns about the way the next version of the DSM is being formulated and the possibility that formerly normal human behaviors will be become "medicalized".   

The DSM is the "Bible" of psychiatrists.  It is used to define what is and is not abnormal behavior.  Psychiatrists like it because it is definitive and descriptive.  Identify the mental illness, name it and medicate it.  Instead of a weekly, one hour psychotherapy session they can do a quarterly, 15 minute "med check" for about the same price.  They also don't have to do the work of actually having a therapeutic relationship with the client or facing a problem they don't know the answer to.  The answer to every problem is "take a pill" and no therapeutic intervention is required.  Just a discussion of symptoms and a prescription.  If the symptoms persist despite medication, the dose is adjusted or the medication is changed.  No matter how many times a patient comes back complaining that they are not getting relief from the symptoms, another pill is the answer to every complaint. 

Insurance companies like diagnosing because it provides a coding system that makes it easy to approve or decline coverage and determine the approved treatment based on the diagnosis.  They too like the fact that weekly psychotherapy sessions are reduced to quarterly med checks. 

Pharmaceutical companies like it because it promotes a line of thinking that is very profitable for them.  Have a problem?  Take a pill.  No, take their pill.  The latest greatest pill.  The one with no generic, of course. 

Scientists and researchers like it because it is said to be based on empirical evidence.

Patients like it because they are convinced that taking a pill is going to fix everything and they won't have to do the hard work of psychotherapy and actually address their issues, change their behavior or change their relationships.  

So what's the problem? 

Normal Human Behavior is being Defined as "Abnormal"

Previously normal behaviors such as shyness are now being defined as something abnormal (i.e. shyness is now "Avoidant Personality Disorder" or "Social Anxiety Disorder") requiring intervention and treatment, typically with a medication.  Grief is now described as depression (instead of a normal reaction to the loss of a loved one) and treated with an antidepressant.  Anxiety caused by living a very stressful lifestyle is now classified as abnormal (instead of a normal reaction to poor lifestyle choices) and treated with anxiolytics.  Even Posttraumatic Stress Disorder is viewed as abnormal and medicated though this is clearly a normal reaction to an environmental stressor.  Instead of working through our problems, feeling our feelings and working through this stress or pain, we medicate ourselves into oblivion, often for the rest of our lives.  Since we do not work through the real issue we do not come out on the other side, we are never healed.

Normal Human Behavior is being "Medicalized"

"Medicalizing" is the process of defining human behaviors as medical conditions to be treated by medical means.  It is the application of the medical model to human actions and reactions.  The medical model views "abnormal" behavior as a disease.  This was a great leap forward at a time when mental illness was viewed as demon possession.  Redefining insanity as an illness instead of a weakness of character or demon possession allowed patients to be treated with more compassion and understanding.  However, in the 21st century it may hinder more than help.

Normal Human Behavior is Now a Permanent Disability

When human behavior is redefined as a chemical imbalance and treated like diabetes or thyroid disorder it dooms the patient to a lifetime illness.  If you view "mood swings" as Bipolar Disorder and classify them as a chemical imbalance you doom the patient to a lifetime of "mood stabilizers" and psychiatric treatment.  The patient can never be healed and never recover.  They will always have to be on meds.  They will always be "abnormal" or "ill".  Instead of having clients who were treated with psychotherapy and recovered we now have permanent patients.

Normal Human Behavior is being Medicated

Combined with the pervasive influence of the big pharmaceutical companies, any "abnormal" behavior defined in the DSM is typically viewed as a biological problem, a chemical or neurological imbalance, and treated with medication.  This is causing serious concerns in the psychological community.   

Christopher Lane, author of “Shyness: How Normal Behavior Became a Sickness" observes, “Before you sell a drug, you have to sell an illness.”  He posits that Big Pharma is creating illnesses to market their pills, much like the invention of Social Anxiety Disorder coincided with the release of Paxil.  Another example is Erectile Dysfunction.  Prior to the discovery of Viagra the decline in a man's ability to obtain and/or maintain an erection was a natural consequence of aging.  Now it is a "dysfunction" which needs medicating. 

See also, Is Social Anxiety Disorder Just a Fancy Name for Shyness?

The Evidence Isn't as Conclusive as the Public has been led to Believe

We are told that the evidence shows that mental illness is a biochemical disorder and that all the research leads to this conclusion.  That simply is not so.  Research has consistently failed to show the efficacy of antidepressants, but has been suppressed.  How?  Why?

Research on psychiatric symptoms is heavily funded by pharmaceutical companies and therefore heavily influenced by Big Pharma.  They will not fund non-medication studies for obvious reasons.  That makes sense.  What is not so obvious is that they have been shown to bury studies which show no difference between patients taking a placebo and patients taking their medications. 

In addition to the influence of Big Pharma on research, many clinicians are starting to question the efficacy of the medical model in assessing psychiatric symptoms.  Clinicians have argued that many diagnoses are not chemical imbalances but reactions to traumas.  Depression seems especially vulnerable to external causalities rather than a biochemical cause.  In fact, rather than a mental illness, proponents of depressive realism maintain that people with depression are more reality based and perceive life more accurately than people without depression. 

See also:

Antidepressant Studies Unpublished, The New York Times
Depression, Helplessness, Hopelessness and External Locus of Control
Depression:  New Thinking on Its Causes
Mood Swings are Normal
Depressive Realism
Trauma and Schizophrenia
Childhood Abuse, Depression, Anxiety, Mood Swings, Bipolar Disorder and Trauma
Bipolar Disorder and Trauma

The Effects of Big Pharma on the Medicalized Model are Disturbing

The U.S. News article continues,

"The most recent edition of the DSM, published in 1994, drew controversy because it turned what had once been a thin guidebook into an 886-page tome that significantly expanded the definition of mental illness. Traits once associated with shyness, for example, became symptoms of "social anxiety disorder".  And drug companies went on to spend millions promoting medicines for those problems. Eyebrows were further raised in 2006 when a study showed that more than half of the researchers who worked on the manual had at least one financial tie to the drug industry."

Dr. Frances, in the Psychiatric Times states that,

"For instance, a seemingly small change can sometimes result in a different definition of caseness that may have a dramatic and totally unexpected impact on the reported rates of a disorder. Thus are false “epidemics” created. For example, although many other factors were certainly involved, the sudden increase in the diagnosis of autistic, attention-deficit/hyperactivity, and bipolar disorders may in part reflect changes made in the DSM-IV definitions.  Note this."

"To promote sales, the companies may sponsor “education” campaigns focusing on the diagnostic changes that most enhance the rate of diagnosis for those disorders that will lead to the increased writing of prescriptions. As I will discuss, there is a great risk of many new “epidemics” based on changes suggested for DSM-V."

"May" sponsor education.  I know they will.  I have seen them work.  This is how antipsychotics became "mood stabilizers".  The drug companies come to a doctor's office or clinic and provide elaborate videos, Power Point presentations, brochures and all kinds of information to "educate" doctors. 

"Another DSM-V innovation would create a whole new series of so-called behavioral addictions to shopping, sex, food, videogames, the Internet, and so on. Each of these proposals has the potential for dangerous unintended consequences by inappropriately medicalizing behavioral problems; reducing individual responsibility; and complicating disability, insurance, and forensic evaluations. None of these suggestions is remotely ready for prime time as an officially recognized mental disorder."

When Big Pharma has a new medication, they push it with a marketing strategy that would blow most people's minds.  Drug reps will take an entire clinic out to lunch and provide, literally, trunkloads of free samples.  They also provide slick, elaborately-executed "educational" programs to doctors on the certain diseases and push the new medication which will magically treat this illness.  If you are a doctor, you are human (yes human, not God), and it can be very tempting to interpret a cluster of symptoms as a particular illness which has a new magic pill which will magically fix it rather than an old illness for which there is not a clear treatment protocol or a poor prognosis.  We all like to be heroes and save the day.  Doctors are no different.

Side effects of the medications are also downplayed.  Most patients don't realize that many "mood stabilizing" medications and several antidepressants can cause serious weight gain.  Antidepressants are well known to reduce a patient's libido.  And "mood stabilizers" can lead to metabolic syndrome when can lead to diabetes.  Many other side effects can be caused by various psychiatric medications which are not well publislhed. 

Big Pharma and American Psychiatry
FDA Complicit in Pushing Prescription Drugs

The Diagnosing Process is Very Subjective

One of the more prevalent complaints about diagnostic procedures is that they are very subjective and highly dependent upon the background, knowledge and individual prejudices of the clinician making the diagnosis.  Currently, many clinicians are complaining that ADHD and Bipolar Disorder are heavily overdiagnosed and indeed it has been my experience that there is a heavy prejudice in favor of diagnosing these two "illnesses".  It is interesting that these are also two diagnoses for which there are "new" medications on the market which are being heavily pushed by the drug companies. 

A doctor's clinical experience can also color the way they diagnose.  A doctor working at the state hospital where the most serious cases often land has seen patients with much more serious symptoms than a psychiatrist in private practice.  The state hospital psychiatrist may be less likely to diagnose a patient experiencing mild symptoms with a serious mental illness than the private psychiatrist who is not regularly exposed to patients with more severe symptoms.  I see this a lot with Bipolar Disorder.  A state hospital psychiatrist will expect to see full blown mania and seriously debilitating depression in order to render the diagnosis while a private practice psychiatrist may diagnose a client with Bipolar Disorder who merely complains of "mood swings". 

See also, The Truth about ADHD
Overdiagnosing Bipolar Disorder
Diagnosis of Mental Illness Hinges on Doctor as Much as Syndrome, Seattle Times

Given these serious and numerous concerns about diagnosing human behavior I always urge people to think for themselves.  Look up any diagnosis you have been given, look up the medications being prescribed for it and above all think for yourself.  Do the symptoms you are experiencing warrant the possible side effects of the medications which have been prescribed?  Does the diagnosis make sense to you?  Are there situational factors which might be causing the symptoms which need to be addressed? 

Some clinicians refuse to diagnose clients at all.  Diagnosing is a view of human behavior through the lens of the "medical model".  The medical model looks for abnormality and views a diagnosis as something abnormal which needs to be fixed.  But it is not the only way to view human behavior or psychiatric symptoms.  There are other models which can be utilized without labeling, stigmatizing, disempowering or medicating clients.  It's important to consider all possible solutions to the problem and make an informed choice. 

With the current state of the psychiatric field, the old caveat for consumers seems especially appropriate.  "Caveat emptor" - buyer beware.

 

Comments

[Janice]

Thankyou so much for breaking ranks (in a way) with your profession and speaking out about what we all suspect. The medicalisation of aging - the cosmetic surgery industry, is another example of this. The Hippocratic oath doesn't seem to be what it once was...

[Kellen]

Hi Janice,

You're very welcome. Therapists are ethically responsible for breaking ranks when practices are harmful, and I feel this one is. Your comment about the cosmetic surgery industry is an excellent example. Thank you for the feedback.

Peace,

Kellen

[erectie]

Well Medicalization is the process by which human conditions and problems come to be defined and treated as medical conditions and problems..It is studied in terms of the role and power of professions, patients and corporations, and also for its implications for ordinary people whose self-identity and life-decisions may depend on the prevailing concepts of health and illness...

[Kellen]

Hi Erectie,

But which concept prevails, and why? What makes the medical model the only valid way of viewing the issue?