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The Book We Love to Hate - Page 2

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Diagnostic Inflation

Again, these complaints are old hat. Ever since number III hit the shelves, critics have argued that the proliferation of new and expanded disorders have led to wildly exaggerated prevalence rates for mental illness, capturing in DSM’s diagnostic dragnet people who otherwise would be considered mostly okay—maybe eccentric, or hot tempered, or worrywarts, or sad, but not sick. Spitzer himself came to worry about disorder inflation. Interviewed in 2007 by British filmmaker Adam Curtis for a documentary called The Trap, he said that in producing DSM-III, “we made estimates of prevalence of mental disorders totally descriptively without considering that many of these conditions might be normal reactions, which aren’t really disorders.” Asked if he had in effect medicalized ordinary human sadness and fear, Spitzer allowed regretfully that “I think we have to some extent. . . . I don’t know if it’s 20 percent, 30 percent. . . . But that’s a considerable amount if it’s 20 percent or 30 percent.

According to its critics, the problem of diagnosis and medication inflation has gotten much worse with DSM-5. They’re particularly disturbed by what they consider the flagrant reification of mental states—the sleight of hand whereby an unpleasant but vague and often ephemeral mental state can, by giving it a name, be magically transmuted into a biological, physical entity and then acted upon as if it were virtually a Newtonian object in space. Thus, depression or anxiety or attention deficit hyperactivity disorder, or almost any disorder, must be caused by an “imbalance of brain chemicals,” or a genetic anomaly, or some neurophysiological glitch in the works, which “explains” the disorder the way a virus “explains” the symptoms of flu, or an inflamed appendix “explains” a sharp pain in the lower right abdomen. This is bad, anti-DSMers say, because once firmly enclosed in the locked box of a diagnosis, no further exploration or questions ensue about what that person is actually experiencing, or in what context. And a diagnosis box begets a treatment box—one disorder, one remedy—most likely pharmaceutical.

DSM-5 is assailed for presumably surpassing previous editions in diagnostic imperialism, occupying ever larger swaths of what used to be considered normal human troubles. The critics are, for example, particularly disturbed by the removal of the bereavement exclusion from the diagnosis of major depressive disorder, thus—notwithstanding the hedges against overuse included in the wording—pathologizing a normal state of sadness, grief, and, yes, depression that attends a serious personal loss. Another new diagnosis that raises hackles is disruptive mood dysregulation disorder, which applies to children exhibiting persistent irritability and severe behavioral outbursts three or more times a week. Besides the limited amount of research substantiating this disorder (an endemic problem in DSM-5), it’s said to pathologize childish temper tantrums and sets kids up for unnecessary medications. Similarly, the new binge-eating disorder—eating to excess at least once a week—would seem to be what millions of Americans do every week, and perhaps nearly every day between Thanksgiving and New Year’s. Premenstrual dysphoric disorder, promoted from the DSM-IV Appendix to full-scale inclusion, incites fury in many women, who maintain that it stigmatizes women and provides yet another opportunity for the pharmaceutical companies to have their way with them.

The DSM-5 Task Force understandably makes much of the long and labored process that went into producing the new manual: reviews of decades of scientific research, 10 years of international conferences, and deliberation involving more than 900 experts from the United States and abroad, including clinicians and researchers in psychiatry, psychology, statistics, epidemiology, neurology, pediatrics, social work, and other disciplines and specialties, as well field trials involving 3,000 patients and roughly the same number of clinicians in different settings throughout the United States and Canada, not to mention thousands of online comments solicited from medical groups, mental health professionals, advocacy organizations, and whoever else wanted to add his or her two cents. If they’d been producing a graduate-school thesis about the history, sociology, philosophy, and practical operation of psychiatric diagnosis in the 21st century, they’d have received an A+. Unfortunately, they could still muster virtually no more scientific evidence for the diagnostic classification system than could the producers of DSMs III and IV—no genetic tests, no brain scans, no biochemical analyses, no cognitive measures—that corresponded with or backed up or pointed to any of the disorders included in it.

This painful fact was brought home in April 2013, just before the release of DSM-5, when Thomas Insel, director of the National Institute of Mental Health (NIMH), which had long backed DSM, pulled the plug. He announced that since the manual lacked scientific validity, NIMH would no longer fund research based on its categories, which were increasingly out of sync with whatever hard data had emerged from studies of the brain and how it worked. In a way, Insel’s statement was a long-expected coup de grace on the scientific pretensions of the whole DSM enterprise. Begun in 1999, the last year of the Decade of the Brain (a 10-year government initiative to advance brain science), DSM-5 represented the high hopes that by the time the manual was ready, it’d reflect enough neuroscientific breakthroughs to change profoundly the way psychiatric diagnoses were made.

Well, not so much, as it turned out. In an interview on National Public Radio’s “All Things Considered,” psychiatrist Michael First, editor of DSM-IV-TR and editorial and code consultant for DSM-5, explained that the new manual couldn’t be significantly more grounded in science than the last edition because the science just wasn’t there. The research hadn’t allowed for a “paradigm shift” in brain science, so “the DSM is not a paradigm shift either. . . . We were hoping and imagining that research would advance at a pace that laboratory tests would have come out. And here we are 20 years later, and we still, unfortunately, rely primarily on symptoms to make our diagnoses.” First went on to recall that in writing a guidebook to DSM-IV, “I stuck my neck out. We said that by the time DSM-5 comes out, Alzheimer’s will be the first diagnosis that has a laboratory test. Actually, you know, I sort of laid it out there. And I [was] wrong. . . . A lot of it really has to do with the brain, [which] is very, very complicated, and it really hasn’t yielded its secrets yet.”

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