DSM-5 Roundup - ReutersLegal - Psychiatrists unveil their long-awaited diagnostic 'bible' | More
Steve Hall
This e-mail contains items from:
ReutersLegal - Psychiatrists unveil their long-awaited diagnostic 'bible'
ReutersLegal - Lawyers worry new measure of mental retardation could prompt more executions
NYT OpEd - Satel: Why the Fuss Over the D.S.M.-5?
NYT - Psychiatry’s Guide Is Out of Touch With Science, Experts Say
Boston Globe Child in Mind blog - Gold: DSM, NIMH on mental illness: both miss relational, historical context of being human
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Most of these items have been circulated by Eric Freedman
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05/17/2013 | ReutersLegal
Psychiatrists unveil their long-awaited diagnostic 'bible'
By Sharon Begley
NEW YORK (Reuters) - The long-awaited, controversial new edition of the bible of psychiatry can be characterized by many numbers: its 947 pages, its $199 price tag, its more than 300 maladies (from "dependent personality disorder" and "voyeuristic disorder" to "delayed ejaculation," "kleptomania" and "intermittent explosive disorder"), each limning the potential woes of being human.
But to the psychiatrist who shepherded the tortuous creation of the "Diagnostic and Statistical Manual of Mental Disorders," perhaps the single most important number is the "5" in its title: This is the DSM-5, not the DSM-V.
That may seem like a cosmetic change, but the American Psychiatric Association, which will release the book on Saturday at its annual meeting, decided to use Arabic instead of Roman numerals because "we want it to be a living document," said Dr David Kupfer of the University of Pittsburgh, the chairman of the task force that produced the DSM-5. Rather than waiting another generation to revise the manual - the DSM-IV was published in 1994 - psychiatrists will regularly update it with, for example, findings from genetics and neuroscience, labeling the revisions DSM-5.1 and DSM-5.2 and so on.
"We used '5' because V.0 and V.1 just don't look good," said Kupfer.
The fact that the world's most powerful psychiatrists (their decisions determine what counts as a mental disorder, and thus what insurers cover and which children receive special services in school) are already building in ways to change the manual is commendable, even its critics say.
But it is also emblematic of the DSM-5's failures, they argue, which include turning normal human behavior and feelings into mental illnesses, and expanding the criteria for disorders until an astonishing one in four U.S. adults has a diagnosable mental illness every year - and even more do over a lifetime.
The latest revision began in 1999 with high hopes for putting mental illness on a scientific footing, using neuroscience in particular to tell the difference between, say, normal sadness and major depression.
That reflected persistent criticism that "drawing a line between sickness and disease is a special problem in psychiatry," said psychotherapist Gary Greenberg, who participated in the "field trials" that tested the DSM-5's proposed diagnostic criteria before they made the final cut. "We don't have blood tests or other objective criteria to distinguish mental sickness from health. So you have a set of criteria that are very common, which means the potential for many people being diagnosed as mentally ill when they're not."
STILL WAITING FOR SCIENCE
The 1,500 experts who contributed to the DSM-5 would have liked nothing better than to base diagnoses on genetics or neuroscience, rather than on subjective judgment and lists of mostly self-reported symptoms such as fear of acting "in a way that will be negatively evaluated" (social anxiety disorder) or approaching and interacting "with unfamiliar adults" (disinhibited social engagement disorder in children).
"It would be great if we had been able to have a paradigmatic shift" by basing the diagnosis of mental illness on biology, as the APA hoped to when it began the DSM-5 process, said Dr Jeffrey Lieberman, chairman of psychiatry at Columbia University and president-elect of the APA.
But the science did not arrive in time. "The DSM can only reflect the research we have," said Lieberman." With rare exceptions such as narcolepsy, which can be diagnosed by testing cerebrospinal fluid, there are no objective biological measures for mental illness.
This lack of scientific rigor led the nation's leading mental health official to attack the DSM-5 for a "lack of validity," as Dr Thomas Insel, director of the National Institute of Mental Health, said in a blog post late last month.
The manual bases diagnoses on symptoms, he noted, but "symptoms alone rarely indicate the best choice of treatment." Allergies and flu share some symptoms, for instance, but no doctor would try to treat flu with an antihistamine.
"Patients with mental disorders deserve better," said Insel, who announced that "NIMH will be re-orienting its research away from DSM categories."
Pittsburgh's Kupfer shrugged off this attack. "NIMH expressed that a couple of years ago," he said. "It would be a mistake to reify the DSM for research purposes."
"Reification" has become a buzzword among the DSM's critics. In this context, it means "taking a concept and turning it into a reality," said Greenberg, whose new book, "The Book of Woe: The DSM and the Unmaking of Psychiatry" argues that the manual and the process behind it are hopelessly and dangerously flawed. "The categories are not reliable in a biological sense."
That can cause harm to people who are labeled "mentally ill" when all they have is a variation of normal human behavior, said Greenberg. "The sphere of normality has to have room for some distress, which is part of being human."
On a practical level, "once you have a diagnosis in your medical record you can have trouble getting insurance or a security clearance, and it changes how you think of yourself," said Greenberg.
BLACK-BOX WARNING
Changes that make it easier to qualify as mentally ill - fewer symptoms, lasting for a shorter time - have drawn the most impassioned criticism of the DSM-5. Dr Allen Frances, the psychiatrist who led the development of the last DSM and who has emerged as the new one's fiercest and most eminent critic, warns of a "hyperinflation" of diagnoses and calls for "a black-box warning" in the dozen or so most controversial changes, much like the black-box warning that regulators require on the labels of potentially dangerous drugs.
The black box, he said in a 2012 essay, would indicate the risks of calling people who engage in binge eating, for instance, or who grieve a dead child mentally ill, and would serve as "an admission that the change is a hypothesis," not a scientific fact.
The new DSM does not include more disorders than its predecessor, said Lieberman, "and it shouldn't increase the number of people who warrant a diagnosis of mental illness."
The changes it does make, however, could have far-reaching consequences.
It classifies compulsive gambling as an addiction, the first behavior to be so categorized. That could make it easier for pathological gamblers to get help, said Jeff Beck of the New Jersey Council on Compulsive Gambling and a recovering gambling addict.
The new manual also breaks out compulsive hoarding from obsessive-compulsive disorder and makes it a stand-alone disorder. That should tell clinicians that treatments that work in OCD are not the best way to treat hoarders, said psychologist Randy Frost of Smith College, who has developed a unique therapy for hoarding.
One of the more controversial changes was to eliminate the previous DSM's "bereavement exclusion" for depression. Now, if a father grieves for a murdered child for more than a couple of weeks, he is mentally ill. A footnote in the DSM-5 explains that "the inability to anticipate happiness or pleasure" in such a situation is a diagnostic criterion for the mental disorder of depression.
To some, this smacks of pathologizing a normal, understandable human reaction. "This completely leaves the person out of the equation and turns people into patients," said psychotherapist Eric Maisel, a critic of the DSM. "The DSM claims that an unwanted, distressing feeling is a sign of a disorder rather than being just a feeling, and it isn't at all interested in whether your circumstances could have caused those feelings."
It is important to consider circumstances, he said, because if someone experiences deep anxiety as a result of losing her job, becoming ill or facing foreclosure, "the remedy shouldn't be a pill," the usual outcome of a diagnosis of "generalized anxiety disorder."
The DSM-5 will likely reduce diagnoses of autism spectrum disorders (ASD). It eliminated Asperger's syndrome and tightened the ASD criteria.
While no one wants to see children incorrectly labeled, said Katie Weisman of the patient advocacy group Safe Minds, "children who were borderline cases under the previous DSM now won't get a diagnosis, which means they won't be eligible" for early, intensive behavior therapy - or won't have it paid for by insurance.
A mother of triplets on the autism spectrum, Weisman says "I'm not sure my boys would be where they are today" - in regular school classrooms, not special education - "without these services."
Whether the critics' fears come true will become clear only once psychiatrists, psychologists and even primary-care providers - who write the majority of prescriptions for drugs to treat mental illness - begin using the new DSM. "We're trying to establish accurate and reliable guidelines, and you can't completely control how they're applied," said Columbia's Lieberman. "The problem is not with the instrument but with the way it's used."
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http://newsandinsight.thomsonreuters.com/Legal/News/ViewNews.aspx?id=77171
5/13/2013 | ReutersLegal
Lawyers worry new measure of mental retardation could prompt more executions
By Elizabeth Dilts
(Reuters) - A new standard from the country's leading psychiatric association to diagnose mental retardation could allow courts to execute convicted criminals with IQ scores below 70 more easily, say death penalty lawyers.
The Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association (APA), is the standard guidebook of psychiatric disorders and is used by clinicians to identify and diagnose psychiatric illnesses.
Each new edition is scrutinized by mental healthcare providers and the pharmaceutical industry for changes in definitions as well as new categories of illnesses. Such shifts can have enormous economic, social and legal implications and often are the subject of controversy.
The fifth edition of the book since it was first published in 1952, or DSM-V, is due to be released May 22. Already it has prompted concern from death penalty lawyers because of the change in the way the manual defines mental illness, or intellectual disability, the new name given in DSM-V.
Earlier editions of the DSM defined mental retardation as an IQ score below 70 accompanied by an inability to meet certain developmental norms, such as bathing regularly or maintaining work. Based on that IQ benchmark, the U.S. Supreme Court ruled in Atkins v. Virginia in 2002 that it is illegal to execute a mentally handicapped person.
But the editors of DSM-V have dropped the 70 IQ score as an indicator of mental retardation and instead recommend that clinicians consider IQ scores while analyzing an individual's behavior to determine if he or she meets the developmental standards.
VARYING STATE LAWS
Making the definition of mental retardation more subjective could prompt more courts to subvert Atkins, said David Dow, a death penalty lawyer in Houston whose client Marvin Wilson was executed in Texas last summer despite his IQ score of 61.
"There are a lot of courts that are hostile to the basic legal doctrine the Atkins case established," Dow said. "When you replace a test that is one part objective, one part subjective with a solely subjective test, it becomes easier for courts that are hostile to the constitutional principle of Atkins to evade that criterion."
While it is illegal under Atkins to execute someone who was diagnosed mentally handicapped, states have the leeway to determine what criteria are used and who makes the diagnosis, said Richard Dieter, executive director of the Death Penalty Information Center. Consequently, states like Texas, Georgia and others have their own statutes outlining criteria to diagnose a convicted criminal as mentally retarded.
From 2002 to 2012, only a quarter of the death row inmates who claimed to have mental retardation were granted stays of execution, according to research by John Blume, director of Cornell University Law School's Death Penalty Project. This included cases that had exhausted all appeals from the time of the Atkins decision to the end of 2012.
"Judges and jurors have stereotypes of what it means to be mentally retarded," Blume said. "There is a problem with people who have lower than 70 IQ scores getting executed in spite of the Atkins ruling, and under the new DSM guidance, that problem is only going to get worse."
IGNORING DSM-V
According to Darrel Regier, vice chairman of the task force that produced the DSM-V revisions, the DSM is developed to provide guidelines for diagnosing mental illnesses for clinicians, not to provide treatment or judicial guidelines, and the test scores are only useful when interpreted by a clinical expert.
The DSM-IV's reliance on an IQ score led, in some cases, to jurors sentencing people with IQ scores of 71 or 72 to death, in spite of the test's five-point margin of error, Regier said.
"A single IQ point on a test can have profound implications for life and death without (clinical) interpretation," he said.
James Harris, the founding director of the Developmental Neuropsychiatry Program at the Johns Hopkins University School of Medicine and a member of the DSM-V work group, said the criteria focus on three areas of adaptive functioning: academic, social and practical.
Looking at a death row inmate's social adaptive area, an expert can examine how gullibility may have led the inmate into a crime, which could support a claim of mental retardation, Harris said in an email.
"We believe that we are providing the courts with a more fine-grained means to consider adaptive functioning more comprehensively and more meaningfully," Harris said.
Lawyer Susan Orlansky of Feldman Orlansky & Sanders said Texas's individualized statutes are the reason her client, Elroy Chester, will be executed even though he meets the lower-then-70-IQ standard. Chester was convicted in 1998 of fatally shooting a firefighter and confessed to killing four other people in the south Texas town of Port Arthur. He is scheduled to be executed June 12. Orlansky does not think changes in the reliance on IQ scores would impact the decision in Elroy's case.
"Personally, I think if the Texas court system is willing to ignore the DSM-IV, I don't know why they wouldn't be just as willing to ignore the DSM-V," she said.
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https://www.nytimes.com/2013/05/12/opinion/sunday/why-the-fuss-over-the-dsm-5.html
May 12, 2013 | Sunday New York Times Week in Review OpEd
Why the Fuss Over the D.S.M.-5?
By SALLY L. SATEL, M.D.
LATER this month, the American Psychiatric Association will unveil the fifth edition of its handbook of diagnoses, the Diagnostic and Statistical Manual of Mental Disorders. Fourteen years in the making, the D.S.M.-5 has been the subject of seemingly endless discussion.
The charges are familiar: the manual medicalizes garden-variety distress, leads doctors to prescribe unnecessary medications, serves as a cash cow for the association, and so forth.
But many critics overlook a surprising fact about the new D.S.M.: how little attention practicing psychiatrists will give to it.
There are dozens of revisions in the D.S.M. — among them, the elimination of a “bereavement exclusion” from major depressive disorder and the creation of binge eating disorder — but they won’t alter clinical practice much, if at all.
This is because psychiatrists tend to treat according to symptoms.
So why the fuss over D.S.M.-5? Because of the unwarranted clout that its diagnoses carry with the rest of society: They are the passports to insurance coverage, the keys to special educational and behavioral services in school and the tickets to disability benefits.
This is a problem because the D.S.M. is an imperfect guide to predicting what treatments will benefit patients most — a reality tied to the fact that psychiatric diagnoses are based on clinical appearances that tend to cluster, not on the mechanism behind the illness, as is the case with, say, bacterial pneumonia.
Simply naming a mental illness does not necessarily point the way to effective treatment. This is why patients often qualify for more than one diagnosis, and why many have poor responses to medications.
Psychiatric assessment is imprecise because the causal systems that drive mental illness are daunting. Dozens of genes contribute to the development of the disorders we call autism, schizophrenia, bipolar illness, severe depression and A.D.H.D. Two people with the same genetic predisposition to mental illness may manifest their conditions differently. Why? Because a patient’s clinical picture depends on a jumble of other factors, including childhood adversity, head trauma, life experience and simple chance.
None of this is news to the framers of the D.S.M.-5. In fact, many psychiatrists had hoped to revise the approach to classifying mental illness. Instead of beginning with categories based on symptom groupings (e.g., schizophrenia, bipolar disorder and panic disorder) and working backward to their neurobiological origins, many researchers wanted to base classification on underlying biology.
To this end, investigators have made promising inroads by defining basic functions like working memory and fear circuitry that are disrupted in people with mental illness. Yet they are not able to generate a taxonomy that links particular types of dysfunction to clinical phenomena.
This will most likely change as researchers learn more about genetics, brain circuitry and cognitive data to fashion better guides to what to prescribe for patients, and in terms of what new compounds to develop.
Meanwhile, the D.S.M. offers discrete categories. At the least, these provide a common language practitioners can use to discuss patients. What’s more, even the most refined biological therapies will work best when coupled with efforts to help patients change troubling habits and to explore the subjective experiences of illness.
In deference to this complexity, the D.S.M. cautions users against taking too literally the sharp boundaries between disorders and between illness and the normal difficulties of life. Unfortunately, however, key public institutions often disregard these caveats.
Insurance companies cover services only if there is a diagnosis. Yet, the suffering of a patient who doesn’t have the symptoms required to qualify for a diagnosis is no less real and no less worthy of professional attention.
While it is true that the D.S.M. generally affords physicians enough leeway to shoehorn patients into some kind of diagnostic cubby for billing purposes, this flexibility can also backfire. In the employment context, for example, new or broadened disorders will most likely spur an increase in accommodation requests under the Americans With Disabilities Act and claims under state workers’ compensation laws.
School districts also rely on the D.S.M. Conditions like autism, A.D.H.D. or conduct disorder must be diagnosed in students in order for them to qualify for special therapies.
Parents press physicians to give children diagnoses, falsely inflating numbers of those with autism and A.D.H.D. It makes more sense to provide therapeutic services based on a child’s degree of impairment at school, at home and with peers.
Diagnoses also figure in disability determination. The Social Security Administration, for example, requires physicians to make a diagnosis before it will consider a benefit claim. Here, the error is mistaking a diagnosis for a prognosis.
I recall Laura, a 50-year-old university secretary who lived with her ailing mother. She spoke of being “suffocated in that mausoleum of a house,” but when her mother died, instead of feeling liberated, she was immobilized for weeks, barely eating, contemplating suicide and sleeping most of the day.
Laura brought up the possibility of being declared disabled. And with a D.S.M.-5 diagnosis of “major depression,” she could have been. Thankfully, she was willing to try treatment first. Although she was still troubled, psychotherapy and an antidepressant enabled her to return to work. Had Laura obtained disability benefits instead, her occupational lifeline would have been severed, along with her sense of purpose, daily structure and opportunities for socializing. Her home would have seemed even more like a tomb.
The media will trumpet the release of the new D.S.M., but practicing psychiatrists will largely regard it as a nonevent. Unfortunately, the same cannot be said for other institutions — insurance companies, state and government agencies, and even the courts — which will continue to imbue the D.S.M. with a precision and an authority it does not have.
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Sally Satel is a psychiatrist, resident scholar at the American Enterprise Institute and co-author of the forthcoming book “Brainwashed: The Seductive Appeal of Mindless Neuroscience.”
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http://www.nytimes.com/2013/05/07/health/psychiatrys-new-guide-falls-short-experts-say.html
May 7, 2013 | New York Times
Psychiatry’s Guide Is Out of Touch With Science, Experts Say
By PAM BELLUCK and BENEDICT CAREY
Just weeks before the long-awaited publication of a new edition of the so-called bible of mental disorders, the federal government’s most prominent psychiatric expert has said the book suffers from a scientific “lack of validity.”
The expert, Dr. Thomas R. Insel, director of the National Institute of Mental Health, said in an interview Monday that his goal was to reshape the direction of psychiatric research to focus on biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms.
While the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., is the best tool now available for clinicians treating patients and should not be tossed out, he said, it does not reflect the complexity of many disorders, and its way of categorizing mental illnesses should not guide research.
“As long as the research community takes the D.S.M. to be a bible, we’ll never make progress,” Dr. Insel said, adding, “People think that everything has to match D.S.M. criteria, but you know what? Biology never read that book.”
The revision, known as the D.S.M.-5, is the first major reissue since 1994. It has stirred unprecedented questioning from the public, patient groups and, most fundamentally, senior figures in psychiatry who have challenged not only decisions about specific diagnoses but the scientific basis of the entire enterprise. Basic research into the biology of mental disorders and treatment has stalled, they say, confounded by the labyrinth of the brain.
Decades of spending on neuroscience have taught scientists mostly what they do not know, undermining some of their most elemental assumptions. Genetic glitches that appear to increase the risk of schizophrenia in one person may predispose others to autism-like symptoms, or bipolar disorder. The mechanisms of the field’s most commonly used drugs — antidepressants like Prozac, and antipsychosis medications like Zyprexa — have revealed nothing about the causes of those disorders. And major drugmakers have scaled back psychiatric drug development, having virtually no new biological “targets” to shoot for.
Dr. Insel is one of a growing number of scientists who think that the field needs an entirely new paradigm for understanding mental disorders, though neither he nor anyone else knows exactly what it will look like.
Even the chairman of the task force making revisions to the D.S.M., Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh, said the new manual was faced with doing the best it could with the scientific evidence available.
“The problem that we’ve had in dealing with the data that we’ve had over the five to 10 years since we began the revision process of D.S.M.-5 is a failure of our neuroscience and biology to give us the level of diagnostic criteria, a level of sensitivity and specificity that we would be able to introduce into the diagnostic manual,” Dr. Kupfer said.
The creators of the D.S.M. in the 1960s and ’70s “were real heroes at the time,” said Dr. Steven E. Hyman, a psychiatrist and neuroscientist at the Broad Institute and a former director at the National Institute of Mental Health. “They chose a model in which all psychiatric illnesses were represented as categories discontinuous with ‘normal.’ But this is totally wrong in a way they couldn’t have imagined. So in fact what they produced was an absolute scientific nightmare. Many people who get one diagnosis get five diagnoses, but they don’t have five diseases — they have one underlying condition.”
Dr. Hyman, Dr. Insel and other experts said they hoped that the science of psychiatry would follow the direction of cancer research, which is moving from classifying tumors by where they occur in the body to characterizing them by their genetic and molecular signatures.
About two years ago, to spur a move in that direction, Dr. Insel started a federal project called Research Domain Criteria, or RDoC, which he highlighted in a blog post last week. Dr. Insel said in the blog that the National Institute of Mental Health would be “reorienting its research away from D.S.M. categories” because “patients with mental disorders deserve better.” His commentary has created ripples throughout the mental health community.
Dr. Insel said in the interview that his motivation was not to disparage the D.S.M. as a clinical tool, but to encourage researchers and especially outside reviewers who screen proposals for financing from his agency to disregard its categories and investigate the biological underpinnings of disorders instead. He said he had heard from scientists whose proposals to study processes common to depression, schizophrenia and psychosis were rejected by grant reviewers because they cut across D.S.M. disease categories.
“They didn’t get it,” Dr. Insel said of the reviewers. “What we’re trying to do with RDoC is say actually this is a fresh way to think about it.” He added that he hoped researchers would also participate in projects funded through the Obama administration’s new brain initiative.
Dr. Michael First, a psychiatry professor at Columbia who edited the last edition of the manual, said, “RDoC is clearly the way of the future,” although it would take years to get results that could apply to patients. In the meantime, he said, “RDoC can’t do what the D.S.M. does. The D.S.M. is what clinicians use. Patients will always come into offices with symptoms.”
For at least a decade, Dr. First and others said, patients will continue to be diagnosed with D.S.M. categories as a guide, and insurance companies will reimburse with such diagnoses in mind.
Dr. Jeffrey Lieberman, the chairman of the psychiatry department at Columbia and president-elect of the American Psychiatric Association, which publishes the D.S.M., said that the new edition’s refinements were “based on research in the last 20 years that will improve the utility of this guide for practitioners, and improve, however incrementally, the care patients receive.”
He added: “The last thing we want to do is be defensive or apologetic about the state of our field. But at the same time, we’re not satisfied with it either. There’s nothing we’d like better than to have more scientific progress.”
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http://www.boston.com/lifestyle/health/childinmind/2013/05/dsm_and_nimh_on_mental_illness.html
May 8, 2013 @ 09:00 PM | Boston Globe Child in Mind blog
DSM, NIMH on mental illness: both miss relational, historical context of being human
by Claudia M Gold
It seems that the National Institute of Mental Health (NIMH) may have dealt a death blow to the recently published Diagnostic and Statistical Manual of Mental Disorders (DSM 5) when the organization declared they would no longer fund research based on the DSM system of diagnosis. The views of NIMH director Thomas Insel were referenced in the recent New York Times article on the subject.
His goal was to reshape the direction of psychiatric research to focus on biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms.
I am no fan of the DSM system, which reduces complex experience to lists of symptoms; focusing on the "what" rather than the "why." However, the NIMH model has limits as well. There seems to be a wish to study mental illness in the same way we study cancer or diabetes. While I certainly have great respect for the complexity of the pancreas, or the process of malignant transformation of cells, trying to understand the brain/mind in an analogous way seems to be an unnecessary and even undesirable reduction of human experience.
What is missing from both paradigms is recognition of the relational and historical context of being human. Fortunately there seems to be awareness that neither paradigm is complete. The Times article goes on to say:
Dr. Insel is one of a growing number of scientists who think that the field needs an entirely new paradigm for understanding mental disorders, though neither he nor anyone else knows exactly what it will look like.
The growing discipline of Infant Mental Health offers just such a paradigm. This discipline is characterized by four key components. First and foremost, it is relational, recognizing that humans (and that includes their genes and brains) develop in the context of caregiving relationships. Second, it is multidisciplinary. Experts in infant mental health offer different perspectives. They come from many fields, including, among many others, developmental psychology, pediatrics, nursing, and occupational therapy. Third, it encompasses research, clinical work and public policy. The field looks at mental health within the context of culture and society. And last, it is reflective, looking at the meaning of behavior, not simply the behavior itself. The ability to attribute motivations and intentions to behavior is uniquely human, and research has shown that this capacity is closely linked with mental health.
Unfortunately when people hear the term infant mental health, they imagine babies lying on the couch. In reality, the field offers a way of understanding all of human experience, well beyond infancy. I recently taught a course on infant mental health to clinicians at the Austen Riggs Center, a hospital that offers intensive inpatient treatment for severely disturbed patients. None of them are infants- the youngest are in their late teens and most are well into adulthood. My students found the insights from infant mental health very valuable for understanding and treating their patients.
The Center for Disease Control (CDC) Adverse Childhood Experience (ACES) study provides extensive evidence of the long-term effects of early exposure to a range of negative experience, including parental mental illness, divorce, abuse, and neglect, on mental health. The more severe the mental illness, the earlier in life disruptions to development probably occurred. Knowledge of infant mental health (that spans age 0-5) offers a textured understanding of this early experience.
Looking at an individual brain and/or genes, or listing the behavioral symptoms of an individual person, out of relational and historical context, how can one possibly understand the complexity of human experience? This complexity is represented by such things growing up in the home of a Holocaust survivor, a depressed parent, in the setting of ongoing war trauma, with a physically and emotionally abusive parent, or some combination of all of these. A recent article on the blog ACES Too High, "What motivated the Boston bombing suspects?" offers a fascinating look at the Tsarnaev brothers from an ACES perspective. The use of the word “motivation" in the title represents a curiosity about the meaning of behavior that is representative of an infant mental health perspective.
The ongoing research coming from the discipline of infant mental health offers growing knowledge about effective, primarily preventive, interventions. Not only do we need this research to continue, but we also need to grow a workforce trained in infant mental health to offer these interventions on a large scale. When the NIMH looks for a new paradigm towards which to direct funding, I hope they will look to the paradigm of infant mental health.
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Steve Hall
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