Psychiatric label surge alarming
New and controversial changes have been introduced to the latest version of psychiatry's industry bible. PHILIP MATTHEWS reports on what those changes mean for us.
Will the unwell soon outnumber the well? The way that some are talking about the new edition of the bible of psychiatry, that could be possible.
During the six decades since that bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), was first published by the American Psychiatric Association, the labels it contains have multiplied. In 1952, there were 106 listed disorders. Now, there are more than 300. In public and in private, psychiatrists and psychologists will usually agree that is far too many.
Influential United States psychiatrist Allen Frances is one of them. After overseeing an earlier edition of the DSM, Frances has turned against it, talking of "diagnostic inflation" and the "radically increasing rates of disorders" that are affecting children in particular. Some disorders are "questionable" at best. He warns of "fad diagnoses".
Some suspect that the psychiatric industry is in the business of "medicalising" everyday life.
In the latest edition, the DSM-5, which was published last month, grief can be called depression, childhood tantrums are signs of disruptive mood dysregulation disorder and binge eating is a mental illness.
"You have to ask: Is it overdiagnosing and turning life's ordinary ups and downs into medical phenomena?" says Peter Coleman, an Auckland educational and developmental psychologist and president of the New Zealand Psychological Society.
Previously, a diagnosis of depression could not apply within two months of the death of a loved one. That criterion has been dropped.
"I don't think it's appropriate to define a person being sad about ordinary life events as being depressed and having a mental illness," Coleman says.
Coleman and Auckland University psychology lecturer Kerry Gibson have co-authored a statement on behalf of the Psychological Society. You could see it as a local version of the backlash that has greeted the DSM-5 internationally.
They say that they join "many psychologists around the world" in being concerned that changes in the DSM are not supported by clear evidence. They feel that the lowering of the threshold for some diagnoses, including depression, and the addition of various others, "raises the risk of giving a mental health diagnosis to someone who may simply be experiencing normal problems of living".
Their statement also notes the controversial dropping of Asperger's syndrome from the DSM's list of disorders, but reassures the public that "psychologists are trained to use their clinical judgment rather than blindly follow a diagnostic manual" and says it is unlikely that their day-to-day practice will be affected by the diagnostic changes.
David Menkes, an associate professor of psychiatry at the University of Auckland, can also see that the new DSM sets up a balancing act for clinicians.
"There is a real tension, because attracting a diagnostic label isn't always a bad thing," Menkes says. "If you need a diagnosis to understand what's going on or to access treatment, then it can be quite a good thing. On the other hand, if it pathologises normal human experience or gives people an excuse to skive off, then it's not a good thing.
"Any diagnostic classification system is going to get it wrong on one side or the other. We want to get the right people in the tent and everyone else outside it.
"I guess the general impression is that the DSM-5 has probably cast the net too widely, particularly in terms of things like depression."
One in 10 New Zealanders are on anti- depressants and US figures are comparable. You could assume that if the diagnosis of depression is broadened, the numbers on anti-depressants will naturally increase.
Menkes believes that the DSM reflects US private psychiatric practice in particular, including "the not inconsiderable influence of the pharmaceutical industry".
"They might think it's a fine thing that suddenly we've got a new diagnostic category," he says. "We must search assiduously for a medication that might assist in that."
"I think that is a real phenomenon that manifests in all sorts of subtle and not so subtle ways," Menkes adds. "For example, the people on the committees deciding on the DSM criteria are meant to declare conflicts of interest, but the reality is that many of the committees include people with not just one but sometimes multiple competing interests.
"They are big fish in the psychiatric world, but unfortunately the way things work, and conspicuously so in the US, is that people are very engaged with this industry.
"Keeping track of those conflicts of interest and making appropriate recognition of them is a real challenge."
Menkes is not automatically critical of the inclusion of the bereaved in the larger category of the depressed.
There are people who become "seriously depressed in bereavement and actually require treatment", so the intention of that change was "arguably reasonable up to a point". For some, being told to take time off and get over it is not enough, and they are the ones who will benefit.
"The ones who will be harmed are those in the normal range who are having a strong reaction that would be self-limited, that would respond to support from friends, family and clinicians, but who don't need a diagnostic label and almost certainly wouldn't require medication or hospital treatment, yet they might be more likely to get that, at least in North America."
Even the question of influence is a grey area. As his comments show, Menkes expects the DSM-5 to have the greatest impact in the US and says that our Ministry of Health tends to follow the World Health Organisation's International Classification of Diseases (ICD) model. However, both models are generally harmonising and the next edition of the ICD, due out in 2015, is expected to follow the DSM's lead in many ways.
Mental health is "a fairly blurred area," Coleman agrees. By this he means that the DSM's categories are less about scientific fact than the consensus of diagnosticians who "put their heads together to make some sense of mental health disorders".
He believes that psychiatric disorders and the way we understand them are cultural and social as much as they are medical or biological.
"If a person exhibits particular behaviours that are distressing to them or other people, or displeasing or illegal, the tendency is to think, 'Aha, they've got a disease', that something within them is causing that," Coleman says.
"That, generally speaking, is not necessarily true. It is true with some psychiatric disorders that have a clear biological basis or arguably a genetic one, although nobody has discovered that yet, but in many ways it's just a way of conceptualising or summarising a person's problem and trying to assist with formulating a treatment programme for them."
Another way that psychiatric disorders differ from medical disorders is that the DSM will not necessarily predict treatment.
"Certainly, if you have a depressive disorder, the treatment is going to be an anti-depressant of some sort, but there is no clear indication which one and why," Coleman says. "There is no necessary one-to-one link between the diagnosis and the treatment as there would be in clinical medicine."
Coleman's larger point is that in mental health, diagnoses are not "objective standards". This is especially true in relation to children, where diagnoses are often made on the reports of parents or teachers.
"A small criticism I would have is that medical personnel, child psychiatrists and paediatricians are rather too prone to taking the parents' account of problem behaviour at home, which might or might not be real, but often the diagnostician would not know because they haven't observed it themselves or even been to the home."
Adults can describe their own symptoms, which is more reliable.
"When it comes to children, it is more tricky. With some of the diagnostic categories, and attention deficit hyperactivity disorder (ADHD) is a case in point, there are reputable people who would argue it's actually a false diagnosis and a social construction, that it does not exist."
With the DSM-5 as a guide, expect ADHD to increase, because it will now be easier to diagnose adults with ADHD, if the symptoms were noticed before the age of 12. However, there is scepticism, partly because of the potential for drug abuse, given that Ritalin is the approved medication.
Menkes agrees that "there is a need for careful research that tries to sort out whether are we overtreating or undertreating that disorder [ADHD]".
He says there is uncertainty both in New Zealand and overseas about how prevalent it is and what should be done about it.
Menkes sees the new binge-eating diagnosis in a similar way.
"When does this actually become pathology?" he says. "We live in a land of plenty and have a problem with obesity. People are very concerned about gaining weight and, for women particularly, there is an overvalued idea of having an ideal body shape.
"It's a cultural problem, a social problem, more than a psychiatric one."
Mental disorders can come in and out of fashion. Coleman notes that sex addiction and internet addiction were both considered for the new DSM.
"Anything you like doing and repeat rather a lot is now the stuff of an addiction," Coleman says.
"Not too many editions ago [until 1973], homosexuality was a mental disorder. A lot of it is about social construction and the norms of the time and what is approved behaviour by the people who are writing these manuals."
Perhaps the most controversial aspect of the DSM-5 does not involve the addition of new mental disorders, but the disappearance of an existing one. With it, a minority risks losing its hard-won identity.
Asperger's syndrome essentially had a 20-year window.
Paediatrician Hans Asperger observed the milder form of autism in the 1940s, but it did not become an official disorder until the DSM-IV in 1994.
Asperger's syndrome quickly entered popular culture as an almost fashionable label to describe someone nerdish and introverted, charmingly socially inept, but with at least average intelligence.
The cliche said that if you watched Star Trek, understood how computers worked or related to The Big Bang Theory, then you were "Aspie".
Menkes says that Asperger's syndrome has become very acceptable to some people, because it implies normal IQ and perhaps the ability to hold down a full-time job. However, the label became diminished in a similar way to how we downplay obsessive-compulsive disorder (OCD) every time we describe someone who is tidy or punctual as being "a bit OCD".
"When people talk about someone being a bit OCD, what they really mean is that someone has an obsessional or perfectionistic personality style," Menkes says.
"That's different from having an obsessive-compulsive disorder, where you really have to get the clothes pegs in the right order or you have to check that the window is latched five or six times before you can go to sleep."
But Asperger's syndrome hasn't disappeared because the label has been overused. Instead, the criteria defining autism in general has been tightened and simplified. Another related diagnosis, pervasive developmental disorder, not otherwise specified (PDD-NOS), has also gone from the DSM-5.
Studies found that the same children could move between the autism, Asperger's syndrome or PDD-NOS labels, depending on who diagnosed them.
Now, they come under the simplifying umbrella of autism spectrum disorder, and those who are too mild for autism may find themselves in a newly created category - social communication disorder, defined as "a persistent difficulty in the social use of verbal and non-verbal communication".
The Asperger's syndrome community has organised itself online and expressed opposition to its definition disappearing. Some worry that the condition they have proudly made their own will be replaced by the more stigmatising label "autistic". High-profile autism researcher Simon Baron-Cohen argued for Asperger's syndrome as a biologically distinct category.
Other experts wrote letters. Last year, 30 autism researchers from Australia, Europe and the US wrote to the Journal of Autism and Developmental Disorders, concerned that there was "no scientific rationale for a change". They estimated that between 20 and 40 per cent of those diagnosed under DSM-IV criteria would miss out under the new criteria.
How will this play out in New Zealand? The experts note that it is too soon to say, but this is where a label really matters. Will the health and disability providers that currently recognise PDD-NOS and Asperger's syndrome treat the new social communication disorder as equivalent?
The Ministry of Health did not respond to requests for comment, but overseas, some have suspected that the narrowing of the diagnosis has been in response to the demand for services.
Rates of autism have boomed in the past two decades. Experts say we can expect to see the rates decline again, not because there are fewer people with the condition, which is just a collection of observed behaviours, but because psychiatrists have shifted the goalposts.
Coleman notes that there was an enormous increase in the diagnosis of ADHD after it was confirmed as a category in DSM-IV. The new edition will probably increase it further, while autism declines. Such are the swings and roundabouts of the psychiatric world.