When did life itself become a treatable mental disorder? (“I will not buy DSM-5. I will not use it. I will not teach it,”)

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PATRICIA PEARSON
When did life itself become a treatable mental disorder?

PATRICIA PEARSON
(INCLUDES CORRECTION)
Last updated Monday, Apr. 29 2013, 3:19 PM EDT


(Ashley Hutcheson For The Globe and Mail)

Grief is a new psychic territory. You cross into an altered land, and
meet the residents, who greet you as if inviting you into their tribe.
They are kindred. You may have only known them glancingly before,
across tables at a dinner party, or down the hall, but now you know
them, for this passage that you and they have made.Sometimes, several
years slip by with us attired in the proverbial widow’s black. Poetry
and music resonate in new ways. Joy is sweeter; sorrow deeper. Sobbing
helps. Time, eventually, heals, although we are never the same. Some
change utterly.


The experience is so profound that the American Psychiatric
Association’s proposal to recast grief as mental illness in the
revised Diagnostic and Statistical Manual of Mental Disorders (DSM-5),
which will be released next month for use around the world, has jarred
a great many people, both lay and professional. So have several other
revisions, to definitions of anxiety, behavioural addictions, even how
we navigate physical pain.

It is a peculiar and reductive logic about the nature of being human,
this idea that grief – or stress, or bingeing on pie – merits medical
intervention. And it is a logic that pervades the DSM revisions, which
is why the manual is proving wildly controversial on the eve of its
unveiling.

Psychiatrists have resigned from the revision working groups to
protest against various criteria; open letters have been penned by the
British Psychological Society, and the American Society for Humanistic
Psychology; petitions have been signed by thousands of mental-health
practitioners; boycotts are being planned in both North America and
Europe. “I will not buy DSM-5. I will not use it. I will not teach
it,” psychiatrist Patrick Landman, of Université de Paris VII,
declared in Psychology Today, where several professionals have taken
to voicing their fierce opposition with ongoing blogs.

The original edition was published in 1952 in order to standardize
diagnostic criteria, reflecting at the outset the optimistic notion
that our social and emotional lives might be tidily catalogued.
Subsequent revisions have manifest the fashions of the times.
Homosexuality was in at one point. Then that came out, and shyness
went in. What is fashionable now, it seemsfor all intents and
purposes, is expanded catchment.

This is the overriding concern of mental health professionals who
oppose the DSM-5. As the manual grows (the original had 95 mental
disorders; the last edition, 283), they argue that it lowers so many
thresholds for being diagnosed with minor mental illnesses that life,
itself, becomes treatable as disease.

The proposed revisions to Generalized Anxiety Disorder, for instance,
drop the bar practically to the level of being worried about your job
and having muscle tension. You need to have one of four symptoms,
according to psychiatrists who have seen the draft, and be worrying
“excessively” about at least two areas of your life. Your job and your
finances, say. How worried is too worried? What is wrong with waves of
dread when your bank account dwindles to zero?

Allen Frances, a U.S. psychiatrist and professor emeritus at Duke
University who oversaw the previous DSM revisions in 1994, calls this
“a travesty of careless suggestions that will likely turn our current
diagnostic inflation into hyperinflation.”

One of the most decried DSM revisions involves the introduction of
“Somatic Symptom Disorder,” which will be diagnosed in a patient who
displays “excessive and disproportionate thoughts, feelings and
behaviours” in relation to an illness. It doesn’t have to be an
imagined illness, or a medically unexplained illness. It can be
cancer, or gout. If you are plagued by chronic pain, let us say, and
fret about it a lot, then your physician can decide that you are being
unreasonable, and thus declare you disordered.

Of course, clinicians do not have to make such diagnoses. For example,
there’s no imperative to diagnose people with “Major Depressive
Disorder” if they are grieving. But in the DSM-5, the APA removes the
exemption of mourning from a diagnosis of mental illness because there
are no biological markers to distinguish the two states. You cannot
rule out one or the other on the basis of a blood test, or a brain
scan. Therefore, members of the APA have argued, the bereaved deserve
access to the same treatment as everyone else.

The operative assumption behind many of these revisions is that
clinicians will use their best judgment when considering treatment.
“Mental disorders are beyond most people’s everyday experiences,”
insists David Kupfer, chair of the DSM-5 Task Force. “Clinical
training is required in order to make a diagnosis using DSM.” They
won’t really label you mentally ill due to cancer pain; they won’t try
to solve your financial and marital anxieties by prescribing an
atypical anti-psychotic. Stop worrying excessively about the DSM
revisions.

In fact, however, it has become common for people to receive
medication rather than concerted counsel from busy doctors and
psychiatrists, and that is why loosening these criteria is so
problematic. “Psychiatry wants to be just like the rest of medicine,
and a lot of its practitioners have stopped listening to people,” says
Joel Paris, chair of McGill University’s department of psychiatry and
author of An Intelligent Clinician’s Guide to the DSM-5. “The problem
lies not with this particular edition [of the DSM] but with the
ideology behind it, which is that mental illness is neurobiological,
and that psychosocial factors are not that important. This is the
position that has taken over academic and clinical psychiatry over
recent decades, and it has led to a serious overprescription of
medications.”

Here, I think of a friend who went to see a psychiatrist during his
divorce, and emerged from his first session with a diagnosis for “soft
bipolar” disorder and an prescription for anti-psychotics. Love, loss,
guilt, thwarted dreams, sudden shocks, mounting pressures, these are
slings and arrows, not chronic disease.

Dr. Frances frequently points out that even modest changes in
diagnostic criteria lead to outbreaks of mental illness because of the
power and ingenuity of pharmaceutical marketing. The incidence rates
of attention deficit disorder, he offers by way of example, have
tripled in the United States since a small amendment was made for DSM-
IV.

It is, he and others argue, naive to presume that pharmaceutical
companies will not make a meal of the new semantics. Eli Lilly already
has its antidepressant, Cymbalta, in clinical trials for “bereavement-
related depression.” In posting information about the trial, principal
clinical investigator John Shuster said: “We expect that Cymbalta
treatment will be associated with substantial mean reductions in
measures of grief and bereavement, with improvements in measures of
pain, symptom burden, and functional status.”

Is the widow’s veil a symptom burden? Does regaining your functional
status win out over “death’s solemn stillness?”

What is motivating the APA to resist all the criticism is complex.
Some point to a hopeless enmeshment with the agendas of drug
companies, a phenomenon that has been well documented by journalists
and by psychiatrists themselves over the past several years There is
also pressure from patient support groups, and “key opinion leaders,”
which is a euphemism for industry-funded experts.

And there is, ultimately, this obsession with taxonomy, with making
the psyche conform to medical measurements. “They want psychiatric
diagnoses to have solidity, but the fact is that psychiatry has
produced anything but that kind of solidity,” says Edward Shorter, an
historian of psychiatry at the University of Toronto. Psychiatry
remains subjective, conjectural, with one person’s “excessive worry”
being another person’s habit of mind, or cultural bent – something
that looks the same but proves adaptive rather than dysfunctional in a
different cultural context. It will ever be thus, that the mind eludes
the measurement.

Is anxiety disordered? Sometimes, and sometimes not. Sometimes the
focus of one’s dread is irrational, but only because the dread is
displaced. Psychiatrist Aaron Beck, inventor of cognitive-behavioural
therapy, wrote about phobias as an act of displacement. A man loses
his mother and develops, apparently randomly, an acute fear of flying.
It is easier to avoid airplanes than to avoid death. Once, when I was
deeply unsettled by certain personal affairs, I unconsciously ignored
them and decided, instead, that we were all about to die from the
avian flu.

How do you code for and quantify emotional responses that shape-shift?

John Livesley, emeritus professor of psychiatry at the University of
British Columbia, resigned last summer from the Personality and
Personality Disorders Work Group of DSM-5 because he was so appalled
by the vagueness, inconsistency and “stunning disregard for evidence”
that characterized the process of revising diagnoses of personality.
(This is the category that includes sociopaths, narcissists and
borderline personality, among others.)

“Alas,” he says, “the DSM is influenced by a large number of factors
besides scientific evidence.”

Often, those making the decisions are established figures who are
settled in their thinking and resist new ideas, not unlike the old
psychoanalysts who were unable to incorporate fresh insights
questioning female “penis envy,” or whatever begged for a double-take.
They are Ivory Tower figures, too. “Many members of the Work Group,”
Dr. Livesley points out, “do not see patients regularly and some have
never or only rarely seen patients.”

It is easier to ponder how many angels can dance on the head of a pin
when no angel is present to argue.

Here is another concern with the trajectory of the DSM: It has been
steadily undermining the importance and credibility of the major
mental illnesses, which deserve most of medicine’s attention and
resources. “The DSM evolved as a language of communication between
clinicians and researchers,” says psychiatrist David Goldbloom,
current chair of the Mental Health Commission of Canada, “so that they
could be talking about the same observed phenomena when they
summarized it with a diagnostic label. I don’t think it was conceived
of as a biblical embodiment of absolute diagnostic truth of disease,
even if people use/see/fear it that way. There are no biological
markers for any psychiatric disorder presently. Genes code for
proteins, not for the DSM. While I understand the heat about DSM-5 and
share the concern about its potential to medicalize normative human
experience … it is unlikely to change the severity of who I see as a
clinician. The concern about DSM-5 seems to be at its margins.”

At its margins, which is where many of us – the bereaved, the
heartbroken, the flat-broke – reside, this is about what story we want
to tell ourselves about who we are. Our narratives, as we live and
ascribe meaning to them, are richer and more nuanced than what is laid
out in a set of behavioural criteria, or a shrinking number of
physical symptoms. This is why the APA has received such vigorous push-
back on the current revisions. Unwittingly, the DSM-5 revisionists are
contributing to an impoverishment of meaning, and it may be that the
need to generate meaning, to make sense of experience, is more
important to our wellness – at these margins – than drugs.

“Psychiatry has entered the new era of the DSM, yet none of the many
evaluations carried out in its name in the U.S. and Europe has shown
significant or lasting improvement in the mental health of their
citizens,” wrote Patrick Landman, the French psychiatrist who is part
of a movement to boycott the new edition. “To cite just one of many
possible examples, between 2000 and 2009, the consumption of
antidepressants in the OECD countries increased by an average of 60
per cent. No study has shown a decline in the prevalence of
depression. Quite the contrary: The suicide rate in Iceland, a country
that consumes the highest amount of antidepressants per capita, has
been constant for the past 10 years.”

Awkward data, that. Unfortunately, it’s also quantifiable.

Editor's Note: An earlier version of this article on psychology
incorrectly described Aaron Beck as a psychologist. Dr. Beck, the
inventor of cognitive-behavioural therapy is a psychiatrist.




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