For what might strike a lot of people as inside baseball, the debate over the upcoming edition of the Diagnostic and Statistical Manual of Mental Disorders is garnering a lot of media attention.
Reports on the controversial revision, due out in 2013 from the American Psychiatric Association, crop up with regularity, pretty much each time new proposed changes are made public. Lately, the reports have focused on the what a Salon contributor called a "full-scale revolt" on the part of British and American counseling associations, who fear expanded diagnoses will lead to overmedication.
I've explained before that I think the term "overmedication" is a misnomer, because the people who employ it tend to do so without explaining what would constitute an appropriate level of medication. Unfortunately, when journalists and mental health professionals write about the DSM debate, they tend not only to use "overmedication" unquestioningly, but to treat it as an inevitable outcome of the impending revision. That helps get people to care about an otherwise rather abstruse controversy, but it also relies on some questionable leaps of logic.
Because the new manual loosens diagnostic criteria for certain disorders and adds additional conditions to the list of pathologies, critics worry that more people being diagnosed with existing disorders, while others will qualify for diagnoses that presumably would not have merited a label under the old system.
By extension, it would seem, more people will be treated with medication, because that tends to be how we treat psychiatric disorders in America. Indeed, a growing list of DSM diagnoses in recent decades has roughly coincided with increasing numbers of people taking psychiatric meds. But as scientists are fond of pointing out, correlation is not causation.
This line of reasoning is also problematic because it tends to assume that mental health professionals will blindly follow whatever the DSM says. The book is called the "bible" of psychiatry because it is the lingua franca of psychiatric diagnosis, but that doesn't mean it's taken as gospel by everyone who uses it.
In fact, therapists' so-called revolt against the proposed revisions demonstrates this point. The therapists are not protesting because they think the existing manual is perfect and ought not be changed. They applaud the attempt to resolve certain problems with the current DSM, but are concerned that the proposed revisions will magnify existing tendencies to pathologize ordinary emotions and behavior, especially in certain vulnerable populations, such as the elderly, children and teens.
As such critiques demonstrate, many -- perhaps even most -- doctors and mental health professionals already harbor considerable skepticism about the DSM diagnostic system, which categorizes patients' problems based on checklists of symptoms and tends to disregard social and psychological factors. But they buy into the system because they want to be paid, and insurance companies, government agencies and the like typically require a diagnosis for reimbursement.
Clinicians tend to view diagnoses as means to an end, not as voice-of-God pronouncements of absolute truth. That's also true in the case of medication. As the diagnosis is based on symptoms, so, too, is treatment. Even the experts don't definitively understand the underlying causes of mental illness, the best they can do is treat the symptoms.
Often -- perhaps too often -- that involves medication. In many cases, however, mental health professionals are not so much worried about the generic "overmedication" mentioned in media accounts as they are about certain new diagnoses, such as "Attenuated Psychosis Syndrome" and "Disruptive Mood Dysregulation Disorder" leading to certain heavy-duty medications -- namely, atypical antipsychotics -- being prescribed to particular groups, such as young people.
Such concerns are well-founded. But in many situations, including those relating to other contested diagnoses, such as attention deficit/hyperactivity disorder and generalized anxiety disorder, doctors are much more likely, I think, to base their prescribing decisions on the degree of existing dysfunction rather than whether or not a patient technically qualifies for a given diagnosis.
I've witnessed this repeatedly as both a patient and a journalist. In more than a dozen years of seeing various general practitioners, psychiatrists and therapists, I've had many diagnoses assigned to me, none with much conviction.
Invariably, when I've inquired about which condition I "have," clinicians tell me not to worry about the actual diagnosis, that the label is a formality and the relevant thing is identifying the troubling symptoms and minimizing the discomfort they cause me. Yet, just one doctor has ever suggested without prompting that I discontinue or pare down my medication regimen.
Call me overmedicated if you will, but overzealous diagnosis isn't what's driving my pharmacological treatment.
Interviewing young people about their experiences taking psychiatric meds for a book on the topic, I've also been struck by how little stock their prescribing doctors seem to put in their diagnoses. Symptoms frequently change as kids get older, and so, therefore, do diagnoses. In many cases, the people I interviewed weren't even sure what, exactly, their diagnosis was. And they generally didn't justify their need for medication based on the disorder they'd been diagnosed with. Instead, they emphasized the particular symptoms that were troubling them.
And, when those symptoms abated, they often abandoned their medication. Asked why, they didn't declare themselves cured or a particular disorder. Rather, they said that they didn't want to bother with the inconveniences and side effects of meds when their symptoms seemed to have cleared up.
Don't get me wrong: I and many of my interviewees would love to have a doctor enthusiastically embrace a particular diagnosis. It would help give structure, meaning and validation to what we're going through. But the doctors, though often eager to prescribe drugs as treatment, aren't so keen on embracing a particular diagnosis as gospel.
Neither are other mental health professionals. Once, out of curiosity, I looked up the diagnostic code my therapist had recorded on my bill. It was for panic disorder. I asked her why she'd done such a thing -- I haven't had panic attacks since high school. Oh, she replied calmly, she'd listed that as my diagnosis because in her experience insurance companies often covered only "biological" conditions such as panic disorder, not "psychological" ones like generalized anxiety disorder.
"So," I said, "You think I have generalized anxiety disorder?" She demurred. She was skeptical about hard-and-fast definitions. But if I must know, she said, then, yes, probably generalized anxiety better described what I was going through.
None of this, I should note, had any bearing on my prescriptions. The clinician in question was a psychologist, and I saw her for therapy, while a psychiatrist prescribed my meds. The psychiatrist assigned me a different diagnosis altogether. And I only know that because I just looked it up.
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Your article ignores recent reports (GAO, CNN, ABC) on the unquestionable overmedicating of Foster Children.
I don't know who you interviewed, but I suggest you contact Maryanne Godboldo, who's daughter was taken by state agencies after she, based on a doctor's recommendation, took her off Risperdal to which she was having adverse reactions. this is NOT at all an uncommon occurence, as the Film Cut, Poison, Burn and many parents testify.
I don't think you interviewed those from the African American community who spent time in Cherry Hospital, a traditionally African American mental hospital, now with more patients in that minority than others, usually forced there against their will.
I wonder if you've read Marcia Angell's reports on the evidence for ineffectiveness of psychotropic drugs or even considered talking to Dr. Peter Breggin (or consulting the Frontline Report) about how drugs are literally pushed on those returning from Iraq and Afghanistan.
Did you think to mention that many symptoms readily treated with drugs are the result of physical causes like brain injury (which drugs can make worse) - like pellagra (or just niacin deficiency) and other nutritional deficiencies or chemical exposures - allergies - and food additives (see Dr. Doris Rapp's evidence). Trauma alone can be the cause of symptoms.
There is so much you are leaving out in this article that I hope you will consider looking at in the future, for yourself and others.
The Brain Bio Centre website is a good place to start.
It is also a major problem in the field, because our research heavily relies on the DSM. Research, you know, the studies that actually test whether any of this stuff works, treat people who meet criteria for *particular disorders* according to the DSM. So, if your diagnosis is just pulled out of thin air, then there is no research to guide your psychiatrist or your therapist in planning your treatment in a way that will *actually help people with your condition.*
We have to rely on research to guide psychotherapeutic and psychiatric treatment. Otherwise, we are nothing but woo-woo false shamans.
The backlash is coming from people who care about best practices in psychiatric care and are concerned about the ramifications of a DSM which is even more pathologizing of normal experience.
Our system is completely broken. We need functional approaches, we need quality of life to be more important than symptoms, we need behavioral interventions as first line treatment, we need to be able to tell healthy people that emotions are okay and don't always need medicine. We don't have that now. The DSM V will make it even worse.
Most of the DSM diagnoses are "pulled out of the air" ie, subjective - there are few if any physical tests or evidence to back them up. Members vote on which symptoms to place under which category.
You ARE woo-woo false shamans, UNLESS you first screen for ALL possible physical causes of brain or behavioral symptoms BEFORE attaching a DSM Label to those symptoms.
If you'll do the research, you'll learn that pellagra was considered an infectious disease at one time. People were institutionalized; they were acting insane. They had a niacin deficiency as a result of the poverty in the South after the Civil War. They were treated and CURED with niacin.
Though all stages of pellagra may not be seen often today, it's very likely that niacin deficiency occurs, and it is known to occur in alcoholics and others whose diet depletes nutrients.
Again, the Brain Bio Centre is a place to start. Also there needs to be more screening for brain injury before drugging, which can make it worse.