In Better Living Through Chemistry? Part I, I described the history of Psychiatric diagnostic approaches and the problems arising from a dependence on a symptom based diagnostic system versus a system based on an etiological understanding of dysfunction and disease.
In Better Living Through Chemistry: Part II, I described, using patient examples, how the availability of less toxic medications along with the use of subjective symptoms for diagnosis, led to a reconceptualization of unhappiness as a treatable condition, "Depression." In my examples I tired to offer some admittedly superficial guidelines for differentiating unhappiness from the life altering dysfunctional state known as Depression.
At the end of Part II, I commented on two additional problems with our nosology. The first problem involves the constant, metastatic growth, of diagnosable, treatable conditions. I will address this toady. The second point, perhaps the most important point of this series, has to do with the erosion of agency and responsibility introduced by the changes in Psychiatric diagnostic systems and will be addressed in a future post.
In June of this year, Dr. Allen Frances wrote an article published in the Psychiatric Times which addressed some of the unintended consequences of the approach being taken by the DSM-V task force. Since Dr. Frances, currently professor emeritus at Duke, was the chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, his words should carry some weight. His initial concern has to do with the lack off transparency of the DSM-V task force, but he evinces even greater concern about the task force's unacknowledged tendency to increase the fluidity and diminish the boundaries of Psychiatric diagnosis:
A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences
I believe that the work on DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology. First we will explore the excessive ambition, because it has encouraged an excessive tolerance for risk taking.
The DSM-V goal to effect a “paradigm shift” in psychiatric diagnosis is absurdly premature. Simply stated, descriptive psychiatric diagnosis does not now need and cannot support a paradigm shift. There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders. The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even 1 biological test is ready for inclusion in the criteria sets for DSM-V.
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So long as psychiatric diagnosis is stuck at its current descriptive level, there is little to be gained and much to be lost in frequently and arbitrarily changing the system. Descriptive diagnosis should remain fairly stable until, disorder by disorder, we gradually attain a more fundamental and explanatory understanding of causality.
It should be obvious to all but the most blinkered Psychiatrists that our knowledge in the Neurosciences is far too rudimentary to support a diagnostic system. As a result, despite the pretensions of the DSM-V task force, they are forced to rely upon (to my mind a failed paradigm) of descriptive diagnosis. Under such a paradigm, the tendency to expand the filed is irresistible:
There is also the serious, subtle, and ubiquitous problem of unintended consequences. As a rule of thumb, it is wise to assume that unintended consequences will come often and in very varied and surprising flavors. 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.20 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.
This serious unintended consequence occurred despite the fact that careful field testing of the DSM-IV versions of 2 of these disorders had predicted no substantial differences in their rates as measured by DSM-III, DSM-IV, and International Classification of Diseases (ICD)-10 criteria.21,22 The crucial lesson here is that even careful field testing is never completely accurate in predicting what will happen when the system is eventually used in the actual field.
This issue becomes particularly relevant when one considers the skillful pressure likely to be applied by the pharmaceutical industry after the publication of DSM-V. It has to be assumed that they will attempt to identify every change that could conceivably lead to a marketing advantage—often in ways that will not have occurred to the DSM-V Task Force. 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.
Dr. Frances rather easily focuses his irritation on the Drug companies, who stand to make a great amount of money if what were once considered simple human foibles become Psychiatric diagnoses deserving of treatment and medication.
(Does your son spend too many hours playing World of Warcraft? Does your wife spend hours on the computer IM'ing? Is she/he addicted to their crackberry? All need treatment and probably medication, administered and supervised by a Psychiatrist! The conceptual basis of what constitutes an addiction have been attenuated to such an extent that it no longer has any meaning. Addiction was once considered the result of an altered state created by an exogenous chemical which established a new drive which constantly pressed for gratification. If the gratification was delayed or denied, physiological responses resulted which intensified the drive until actions were taken to once again gratify the need state. Today an addition seems to be any behavior which a person enjoys or strongly desires, without which they can become irritable. The disconnect from the conceptual basis of Addiction, that an exogenous chemical directly changes the state of the brain, means that there is no longer any distinction between passions and addictions.)
But that is too limited and too easy a target. There are tremendous incentives currently in place to increase the size and scope of Psychiatric diagnoses. Parents who desire extra services that might give their child an edge in school press for non-toxic diagnoses for their children. Mild ADD or perhaps some minimal "spectrum disorder" diagnosis, are among the epidemic Psychiatric disorders of childhood. People who prefer to medicate a troubled marriage, once diagnosed as "addicted" to the internet or Bipolar because of "mood swings", can use medication to tolerate their unhappy relationship and avoid looking at themselves or their partner's difficulties in relating to each other. The list goes on. By the time DSM-V has done its work, everyone will be diagnosable.
The damage to agency and responsibility are already profound and likely to grow.
To Be Continued...
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