A Critic of The DSM Revision Process

Allen Frances, one of the psychiatrists on the APA task force that drafted the DSM IV, has become one of fiercest critics of the secrecy surrounding the present task force’s effort to draft the future DSM V. An excellent article on this struggle to refashion what’s amounts to the shrinks’ Dead Sea scrolls into the next edition of the shrinks’ best selling bible of diagnosis can be found at Wired Magazines website, Inside the Battle to Define Mental Illness.

I’ve been amused in Dr. Frances to find myself agreeing with a psychiatrist who otherwise would have seemed, to my way of thinking, mainstream and medical model.

Frances, who claims he doesn’t care about the royalties (which amount, he says, to just 10 grand a year), also claims not to mind if the APA cites his faults. He just wishes they’d go after the right ones—the serious errors in the DSM-IV. “We made mistakes that had terrible consequences,” he says. Diagnoses of autism, attention-deficit hyperactivity disorder, and bipolar disorder skyrocketed, and Frances thinks his manual inadvertently facilitated these epidemics—and, in the bargain, fostered an increasing tendency to chalk up life’s difficulties to mental illness and then treat them with psychiatric drugs.

If you have heard anything about Dr. Joseph Biederman and his part in the recent childhood Bipolar epidemic. Dr. Allen Frances points out that this epidemic would not have taken place if the DSM IV had not opened to the door to diagnosing bipolar disorder in children in the first place, and therefore I imagine part of his motivation here may be a matter of penance for his own role in that epidemic. One of his concerns was that the present task force could be paving the way for another such epidemic with proposal of a pre-psychotic condition referred to as psychosis risk syndrome.

This new disease (psychosis risk syndrome) reminded Frances of one of his keenest regrets about the DSM-IV: its role, as he perceives it, in the epidemic of bipolar diagnoses in children over the past decade. Shortly after the book came out, doctors began to declare children bipolar even if they had never had a manic episode and were too young to have shown the pattern of mood change associated with the disease. Within a dozen years, bipolar diagnoses among children had increased 40-fold. Many of these kids were put on antipsychotic drugs, whose effects on the developing brain are poorly understood but which are known to cause obesity and diabetes. In 2007, a series of investigative reports revealed that an influential advocate for diagnosing bipolar disorder in kids, the Harvard psychiatrist Joseph Biederman, failed to disclose money he’d received from Johnson & Johnson, makers of the bipolar drug Risperdal, or risperidone. (The New York Times reported that Biederman told the company his proposed trial of Risperdal in young children “will support the safety and effectiveness of risperidone in this age group.”) Frances believes this bipolar “fad” would not have occurred had the DSM-IV committee not rejected a move to limit the diagnosis to adults.

Psychosis risk syndrome is no longer slated for the DSM V. Instead it has been replaced with something called attenuated psychotic symptoms syndrome.

When the rough draft of the DSM-5 was released, in February 2010, the diagnosis that had galvanized Frances—psychosis risk syndrome—wasn’t included. But another new proposed illness had taken its place: “attenuated psychotic symptoms syndrome,” which has essentially the same symptoms but with a name that no longer implies the patient will eventually develop a psychosis. In principle, Carpenter says, that change “eliminates the false-positive problem.” This is not as cynical as it might sound: Carpenter points out that a kid having even occasional hallucinations, especially one distressed enough to land in a psychiatrist’s office, is probably not entirely well, even if he doesn’t end up psychotic. Currently, a doctor confronted with such a patient has to resort to a diagnosis that doesn’t quite fit, often an anxiety or mood disorder.

Regardless of the label for it, I imagine they will have to come up with a drug treatment for it, and ultimately the course of this syndrome could be either to blossom into full blown psychosis, or to relapse into “normality”, the one “sickness” most doctors are unwilling to treat.

I had felt inclined to respond to a recent article in the New York Times about mental health conditions at Stony Brook University with a blog post about how, no, it isn’t that schools of higher education are getting “sicker” students than they used to be getting, it’s that there are more young people with psychiatric labels now, and a psychiatric label has never been something to prevent a person from going to college. Dr. Frances responded with his own letter to the New York Times in which he attributed this phenomenon, as do I, to over-diagnosis.

The exploding rate of “severe” psychiatric illness on campus is most likely caused by overdiagnosis — not by a decline in the mental health of college students. The people are the same, but the boundary of psychiatry has expanded at the expense of normality.

The childhood “mental illness” label was much less common, tended to be less severe, and was thought of as more treatable just a few years back. I, for one, don’t attribute our present epidemic to a sudden surge in genetic mutations, nor do I attribute it to a raging outbreak of pre-natal negligence.

Psychiatric diagnosis and treatment are enormously helpful for those with severe and persistent symptoms. By all means, let’s diagnose and medicate students who really need it. But the huge increases in the rate of mental illness almost surely represent a medicalization of the expectable difficulties many students have in adjusting to college life.

I doubt that the divide between those with, and those without, severe and persistent “symptoms” is nearly as large as Dr. Frances imagines it to be. I wouldn’t be in too much of a rush to “diagnose and medicate” students either, and certainly not without their consent. The advance of medicalization, on the other hand, is a problem that some of us would very much like to see reversed, as this advance spells absolute disaster and doom for large numbers of people. Reversing this advance is a matter of ending some of the practices that lead to, and sustain, our current epidemic in “mental illness” labeling.

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10 Responses

  1. Another over-diagnosed, but seldom discussed disorder is Borderline Personality Disorder. It is a trash can diagnosis inflicted mainly upon women. Where I live in Michigan there are two primary diagnoses attached to inpatients at the University of Michigan Hospital: Borderline Personality and Bipolar. Both are treated aggressively with medications by University of Michigan psychiatrists. If you are an older patient ECT is the norm at this hospital as treatment for any diagnosis that carries depression as a symptom. In my mind this is criminal.

    • Borderline Personality Disorder, less commonly referred to as Difficult Person Disorder, is diagnosed a lot more often than it used to be. I think you’ve made a very appropriate point by referring to it as a trash can diagnosis. Mental health workers attach this label to people they don’t like. I’ve met a number of women with the diagnosis, I don’t think I’ve met any men with it.

      People bearing Bipolar Disorder labels, of course, mushroomed at some point back in the nineties to where now people with that label outnumber people labeled schizophrenic by a widening margin.

      The practice of using ECT on older people, or anybody else, is physically damaging, and it should be outlawed. You are very right to call it criminal. It is something that should not be done to living creatures.

  2. I was given the Borderline label at the University of Michigan in the 90’s. I always felt it was because I “talked back” to the Psychiatrists, and refused some pretty hazardous drugs. The diagnosis was debunked later by another Psychiatrist I actually respect, who did not understand why I was given this diagnosis…and yet Borderline lives on in perpetuity on my medical record.

    • I think it’s interesting that BPD isn’t generally diagnosed until towards the end of the patient’s career. By this time, the patient has discovered that psychiatry is a bunch of bunk. And psychiatry tries to blame the patient and to deflect this insight and says she has BPD.

      I think it should be a diagnosis that one would wear proudly and loudly. After all, why should there be a stigma attached to a psychiatric diagnosis?

      • Yay! Debunkings!

        Psychiatrists call people bad names. One of those bad names is Borderline Personality Disorder. “Lamebrain” or “a**hole” would make as much sense. I wouldn’t wear any bad name proudly and loudly. I’d diagnose whatever made psychiatrists say bad things about people. Psychiatrists need help!

        I think you can find good things to say about yourself. One of the ways of finding good things to say about yourself is by undiagnosing yourself. The psychiatrist applies his bad word to you. Okay, it needn’t stick. You’ve got a dictionary. You’ve got other words, and some of them are good words. Why not give yourself a good word?

  3. I really don’t care what people call me as long as they call me for supper.

    When you allow people to offend you with a word, then you have already given them far too much power over you. You should use it. Don’t burden yourself with its connotations and ignore them. Pretty soon it becomes a hollow shell because even its denotations have lost relevance. It becomes hackneyed. It ceases to shock. And the people who would want to use it to control are left with nothing.

    Or at least that’s been my experience with language.

    • Yeah, and when a shrink asks me whether I don’t mind if he calls me “bipolar”, “schizophrenic”, “generally anxious”, “borderline”, or what have you, only then will I believe he has any consideration for my feelings (or anybody elses) on the matter. I always thought that was sort of like calling me “E.T.” where I had much rather think of myself as a human being. I don’t think it the least bit odd that before psychiatrists were known as psychiatrists they were known as alienists. Otherwise, I’m wondering where the zipper is to my flesh suit.

  4. I am not a “diagnosis”. I am a human being. Doctors have referred to mw, in my presence as a “borderline”. I resent that. Calling someone “names”, even if you are a so-called professional is damaging in subtle and profound ways. I was diagnosed as “borderline” by a psychiatrist the first time we met. (a “diagnosis which was later debunked by one of the most famous analysts in the world) I bristled and argued with the man, refused his “medication”…Zyprexa…and ordered him out of my room. Psychiatrists consider me angry and difficult, which is amusing, because my family and friends strongly disagree. As punishment for refusing his treatment, this shrink had me PETITIONED. He gave me three days to comply, or, he threatened to commit me to the state hospital. I quickly found a good lawyer, and was out the door within 24 hours. MOST patients, however, are intimidated by Psychiatrists, and internalize these diagnoses. They, in effect, become the “disease”. Psychiatry is pseuodoscience. Nothing more.

    • You were fortunate. Many people cannot afford an attorney. Going to a legal aid service, the only kind of a response I received when inquiring on a institutionalized person’s behalf, was, “We don’t take those kinds of cases”. It can be very frustrating.

      Court appointed lawyers I know from personal experience are the worst. Imagine having a commitment hearing, being given a few minutes to speak with an attorney, and then he doesn’t really mount much of a defense. He probably thinks it is in his client’s best interest to lose the case. His client would disagree with him strenuously if given the chance to do so. The hearing ends up with the forgone conclusion of a kangaroo court, and the client is trashed, judiciously speaking, to the loony bin.

  5. I agree. When I was petitioned, they sent in a legal aid attorney. I asked this woman how much experience she had in handling these cases, and she replied that she was “quite” experienced. I asked her how many clients she had represented at these hearings. She said: three. Her advice to me was to take my meds, and stop “yelling” at the Psychiatrists. I threw her out. Luckily, for me, I live in Ann Arbor, where the University of Michigan has a great law school. I found a listing of faculty, and after about 5 phone calls, landed an attorney who agreed to accept my case pro bono (I am not a wealthy person…I’m a horse trainer. He visited me at the hospital within 2 hours…met with me, and we discussed my options. He believed the U of M had no grounds on which to hold me, and suggested I counter-sue for false imprisonment. He met with the shrink and risk-management at the U of M, and they agreed to release me the next day. I am lucky, only in that, I am a very persistent person. I have community organizing skills, am well-educated, and clear-headed. (As I had refused their drugs.) I truly wish there was an organized group of advocates and attorneys everywhere, to represent individuals who are thrown before these kangaroo courts. As of now, the U of M can petition you one day, and have you in court the very next day. The hearing is held in a small room on the same floor with an American flag and proceedings take place on closed-circuit TV. These patients are rail-roaded. It is an abomination!

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