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Tuesday, March 22, 2011

Is the APA labeling the “problems of daily living” as disease?

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The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders.  The DSM is sometimes referred as “the therapist’s Bible.”  The DSM has enormous on who will and will not be called mentally ill and what the varieties of  mental illness will be.

The leading therapists often disagree about which label to assign to a given patient, and there is less definitive research than one might expect to prove that “A person with diagnosis X will benefit from and not be harmed by treatment Y.” As such, each generation of DSM emerges with some controversy. This was true for the DSM (in 1952), then DSM-II (1968), DSM-III (1980), DSM-III-R (Third Edition Revised) (1987), DSM-IV (1994), and DSM-IV-TR (2000).

As the DSM-5 is being drafted on the heels of the promise of a “paradigm shift,” a debate has been ignited, fueled by the likes of old-guard DSM architects Drs. Robert Spitzer, MD, and Allen Frances MD, on the one hand, and current DSM-5 framers lead by David J. Kupfer, M.D., who are forging relentlessly onward toward a 2013 deadline on the other.  The debate has many facets involving both content and process, but at the center is "what constitutes a mental illness and what are the appropriate targets of psychiatric intervention".

"Contrary to popular belief, the enterprise of psychiatric diagnosis is largely unscientific and highly subjective" according to Harvard psychologist Paula Kaplan, PhD. "I served as an advisor to two of the DSM-IV committees before resigning due to serious concerns after witnessing how fast and loose they play with the scientific research related to diagnosis.  There is a lot of pain and suffering in the world, and it is tempting to believe that the mental health community knows how to help. It is widely believed, both by mental health professionals and the general population, that if only a person gets the right psychiatric diagnosis, the therapist will know what kind of measures will be the most helpful. "

Do  44 million people in the USA have a  mental disorder? 

Or does the DSM encourage an overstatement of mental illnesses? reported in November 2010 that the US Surgeon General estimates that 28% of the US population suffer from either a mental or addictive disorder in a given year.  This is based on the DSM-IV.  The current prevalence estimate is that about 20 percent of the U.S. population are affected by mental disorders during a given year. This estimate comes from two epidemiologic surveys: the Epidemiologic Catchment Area (ECA) study of the early 1980s and the National Comorbidity Survey (NCS) of the early 1990s. Those surveys defined mental illness according to the prevailing editions of the Diagnostic and Statistical Manual of Mental Disorders. The surveys estimate that during a 1-year period, 22 to 23 percent of the U.S. adult population.

DSM IV increased the number of mental illness categories by 25%

DSM-III-R contained 297 categories and DSM-IV contained 374.  Each time a new edition appears, the media ask whichever psychiatrist is the lead editor why a new edition was necessary, each editor replies that it was because the previous edition really wasn’t scientific (Caplan, 1995). And each time a new edition appears, it contains many more categories than does the previous one. 

Are the findings of the DSM 5 premature?

Dr. Frances cautions how the inclusion of spectral views of mental disorder in DSM-5 could contribute to inappropriate medicalization of “problems of daily living” and the sanctioning of pharmacologic interventions for conditions where evidence-based practice does not yet exist (e.g. indiscriminate use of antipsychotics for the “psychosis risk syndrome”).

At the same time, Frances states "for many domains of psychopathology, a spectral view does reflect biological reality and that etiologic discoveries do require a shift to dimensional models of mental illness. However, DSM-V doesn’t need to exist for a dimensional approach to research to take place—such inquiry has already been ongoing for years. In fact, I would argue that DSM revisions should follow this kind of research rather than the other way around. Yet it seems that the move towards dimensionalization in DSM-V has already begun and that an immediate impact on clinical practice is inevitable. 

It is within arenas in which categorical judgments about mental pathology are both essential and have significant and potentially harmful consequences—the aspects of clinical intervention described above as well as with the various “third parties” that use DSM (e.g. governments deciding resource allocation, insurance companies reimbursing for care, the legal system making decisions about moral responsibility)—that thoughtful decisions must be made about how best to adapt to a spectral view of mental illness. It is therefore our collective destiny that ethical discussions about what could occur will soon become practical discussions about what does occur."

Defining mental illness is complicated - where do you draw the line?

 One prominent DSM-IV author has proposed that “relational disorder” be added to the manual. “Relational disorder” would be applied to a couple, neither of whom individually might be considered mentally ill but whose relationship would be considered sick.  It is revealing to picture this scene: Two people sit in a psychiatrist’s office; neither of them is considered mentally ill, though their relationship is; the psychiatrist removes a pill from its bottle…where does the psychiatrist put the pill?

Author: Skip provides support, education, tools, and perspective to individuals with a loved one affected by Borderline Personality Disorder. BPFamily is a non-profit, co-op of nearly 75,000 volunteer members and alumni formed in 1998. We welcome you to join our free 24 hour on-line support community with its nearly 3 million postings and grow with us as we learn to live better lives in the shadow of this disorder. For more information or to register, please click here.

Write comments
  1. This is an incredibly insightful article. If 25% of the us population is mentally ill, then by definition the DSM is too inclusive. We need to understand better where the line of illness is.

  2. I understand that the purpose of the DSM manual is to create a common language for diagnosis, treatment, research, etc. As with many concepts, over the course of history, there needs to be revision based upon new information. The question posed at the end of the article, "where do you draw the line" is a valid one. I'm sure there are some revisions that need to be made from version to version, however, to narrow every dysfunctional aspect of human behavior down into it's own separate category would make this manual difficult for the majority of therapists to use properly. The focus of these revisions should be geared towards increasing the ease of use for the majority who use the manual on a daily basis.