We all have those days when we think to ourselves - this is nuts. Or, that was crazy. Or, I feel insane today. Some of us do struggle with a clinical mental illness, treated or untreated. Many of us will go our entire lifetimes without a psychiatrist or psychologist labeling us with a diagnosis, and some of us that do receive a diagnosis may receive it in error, or for a disorder that has no basis in science. The diagnostic go-to manual for those in the mental health profession is the Diagnostic and Statistical Manual of Mental Disorders (or DSM for short). The DSM has been through many iterations, since before World War 2, and currently the DSM V is in the works. The DSM helps doctors diagnose and treat patients with psychiatric illness, by outlining the symptoms and diagnostic criteria for various diseases of mental health. It serves as a template for insurance company coverage of mental illness and affects research funding in these areas. Its importance and influence in the field of mental healthcare is unparalleled. Its history of controversy is also unparalleled.
The history of psychiatric classifications and the evolution of the DSM is an interesting one. The American Psychiatric Association provides a historical overview on their web page, including these excerpts:
What might be considered the first official attempt to gather information about mental illness in the United States was the recording of the frequency of "idiocy/insanity" in the 1840 census. By the 1880 census, seven categories of mental illnesses were distinguished: mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy.
The American Psychiatric Association Committee on Nomenclature and Statistics developed a variant of the ICD-6 (International Classification of Diseases) that was published in 1952 as the first edition of the Diagnostic and Statistical Manual: Mental Disorders (DSM-I). DSM-I contained a glossary of descriptions of the diagnostic categories and was the first official manual of mental disorders to focus on clinical utility. The use of the term “reaction” throughout DSM-I reflected the influence of Adolf Meyer's psychobiological view that mental disorders represented reactions of the personality to psychological, social, and biological factors.
DSM-II was similar to DSM-I but eliminated the term “reaction.” DSM-III introduced a number of important methodological innovations, including explicit diagnostic criteria, a multiaxial system, and a descriptive approach that attempted to be neutral with respect to theories of etiology. This effort was facilitated by extensive empirical work on the construction and validation of explicit diagnostic criteria and the development of semistructured interviews. Several years later, in 1994, the last major revision of the DSM, DSM-IV, was published. Numerous changes were made to the classification (e.g., disorders were added, deleted, and reorganized), to the diagnostic criteria sets, and to the descriptive text based on a careful consideration of the available research about the various mental disorders.
However, this overview is very politically correct. It does not attempt to address the many controversies that have surrounded the DSM over the years, or the so called ‘diseases’ contained within various DSM editions which were later removed when they were found to be without scientific basis. Currently, the DSM V is in the works, with drafts released earlier this year. AAAS/Science has done extensive coverage on the release of these drafts in February/March 2010. Rewrites to this fifth version of the psychiatric bible include the addition for the first time of behavioral addictions, when previously the only addictions given classification in the DSM were those for drugs, alcohol and gambling. Now, Internet Addiction may be added to this list, as it is poised to sit in the appendix of DSM-V. When or how one might diagnose this vague disorder is still a subject of controversy.
Other behavioral addictions are also addressed: binge-eating is no longer in the appendix and will appear in the eating disorders category, and sex-addiction was found to not be scientifically founded for inclusion in DSM-V (unlike gambling, which has a host of scientific findings to support its existence).
Other revisions for DSM-V include wording about OCD-spectrum disorders (in the Anxiety category), which will now include hoarding and Tourrette syndrome. The formerly 12 personality disorders will now be only 5 in number (narcissistic personality is out, borderline personality stays in). One of the controversial revisions for DSM-V is whether or not to include anxiety in the list of symptoms for depression. Overall, today’s goal for many in the mental health profession is to align the DSM with scientific data including a brain-based classification of diseases.
Some of the controversy surrounding the DSM throughout the years has centered around the diagnosis of personality disorders. Borderline personality used to sit somewhere between neurotic and psychotic (think the diagnosis of Winona Ryder’s character in Girl Interrupted). Today, a patient must display 5 of 9 possible symptoms including impulsiveness, self-mutilating behavior, or chronic feelings of emptiness. However, this disorder is still considered one of the most controversial to diagnose correctly (see this list from Live Science).
Another controversy has been the inclusion of homosexuality as a mental disorder in previous versions of the DSM. In 1973 the APA declared that homosexuality is not a disease, but it remained in the 1980 DSM-III, to be removed for good only relatively recently, in 1986.
Gender identity disorder is another DSM-V controversy, given that the criteria for diagnosis appear to reflect societal discomfort with a biological phenomena, instead of actual mental illness.
These and other controversial inclusions and removals for the DSM-V will continue to be discussed, with the final DSM-V expected to be released in 2013.
AAAS provides this DSM-V at a glance:
Psychotic Disorders
Old subtypes for schizophrenia will be discarded. Diagnosiswill be made based on common symptoms such as hallucinationsand thought disorder, as well as their duration and severity.
Newly proposed is "psychosis risk syndrome" for people showingwarning signs such as delusions, hallucinations, or disorganizedspeech and experiencing distress. Critics say this could stigmatizemany young people. Defenders say early identification couldhelp them.
Mood Disorders
DSM-IV lists nine symptoms on which to base diagnosis of depression.The proposed one emphasizes three basic dimensions: depressionwith anxiety, with substance abuse, and with suicidality. Anew diagnosis of "mixed anxiety depression" is proposed. Thethreshold for bipolar diagnosis is lowered slightly, to accommodatedepression with only one or two episodes of mania. This changerecognizes the fact that some antidepressants can trigger amanic episode in the vulnerable.
Anxiety Disorders
The main change is the expansion of obsessive-compulsive disorder(OCD) spectrum, which now pulls in disorders from far-flungparts of DSM-IV. These include Tourette syndrome, body dysmorphicdisorder (obsession with changing a normal body part), and trichotillomania(hair-pulling). "Hoarding disorder" has also been added to thespectrum. There is still debate over whether OCD should havea designation separate from anxiety disorders.
Personality Disorders
The old DSM laundry list of 12 personality disorders will betrimmed to five: borderline, schizotypal, avoidant, obsessive-compulsive,and antisocial/psychopathic. ("Psychopathic," eschewed in earlierDSMs, is now back.) The other diagnoses will be superceded bya "mix and match" menu of symptoms that reflect two types ofcore pathologies: disturbances related to self-concept, andthose related to interpersonal functioning such as cooperativenessand empathy.
Addiction and Related Disorders
Vocabulary is being overhauled. "Dependence" (which impliesphysical and not necessarily psychological dependence) is out."Abuse" is also out as unsupported scientifically. Instead,varying degrees of "use disorder," as in "alcohol use disorder,"are proposed.
"Gambling disorder" has achieved the status of addiction, basedon behavioral and biological similarities to substance addiction."Internet addiction" is under consideration but hasn't yet madethe grade.
Eating Disorders
New addition is "binge eating," which has been moved from theDSM Appendix to become a full-fledged disorder.
Sexual and Gender Identity Disorders
"Gender identity disorder" has been retained despite pressurefrom transsexual advocates. Several new diagnoses, including"sexual interest/arousal disorder in women," are proposed. Themost controversial is a proposal for "hypersexual disorder,"involving recurrent and distressing sexual "fantasies, urgesand behavior."
ADHD and Disruptive Behaviors
Changes to attention disorder diagnoses are still under consideration.The group proposes a new subtype of conduct disorder that includescallous, unemotional traits (such as lack of guilt or remorse),citing recent evidence that this subset of children and adolescentsmay be more prone to chronic violent behavior and require differenttypes of treatment.
Childhood and Adolescent Disorders
Additions include specific criteria for diagnosing post-traumaticstress disorder in preschool children and "temper dysregulationdisorder with dysphoria," characterized by severe temper outburstsalternating with negative mood states. Children with this problemare often diagnosed with juvenile bipolar disorder under DSM-IV.
Neurocognitive Disorders
This new category would subsume various DSM-IV diagnoses, dividingthem into major and minor disorders. Major neurocognitive disorders(such as various forms of dementia) involve a decline that interfereswith independent living. Minor disorders would include mildcognitive impairment (MCI), a suite of memory and other problemsconsidered a possible prelude to Alzheimer's. Elevating MCIto a formal diagnosis could facilitate clinical trials aimedat preventing Alzheimer's.
Neurodevelopmental Disorders
Several DSM-IV diagnoses would be consolidated into a single,broader diagnosis of "autism spectrum disorders." These includeAsperger's syndrome, a high-functioning form of autism. Thegroup says there is no scientific justification for the term,but the change has been strenuously resisted by Asperger's advocates.Also, the term "mental retardation" would be replaced with "intellectualdisabilities."
Sleep-Wake Disorders
DSM-IV distinguishes "primary insomnia" from insomnia causedby other conditions. These would be merged into a single diagnosisin DSM-V, with clinicians asked to note accompanying dimensionssuch as depression or heart disease. "Restless leg syndrome"would be elevated to a formal diagnosis.
Somatic Distress Disorders
Several diagnoses that deal with bodily complaints would befolded into a new umbrella diagnosis of "complex somatic symptomdisorder" on the grounds that DSM-IV diagnoses such as somatizationdisorder and hypochondriasis have common features such as chronicphysical complaints and distorted perceptions of symptoms.
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Michael Steinberg
doctorwascher
Paul Hinrichs
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Comments
So cool to see it written by a PHD. This is such a rich topic cause it's everywhere- every one is a DSM specialist and it's out of control.
Thank goodness the research goes on and they keep shuffling their boxes around :) In some cases it's very helpful. I'm all for getting a crappier (more stigmatizing) label if it's accompanied by drugs that actually work.
When I was a boy, when you said someone was "mentally ill," that meant they were, you know, crazy. The definition of mental illness has been broadened so much I no longer see any difference between "mental illness" and "unhappiness."
Our paleolithic ancestors trekked for hundreds of miles in search of game, ran down wooly mammoths, and battled giant cave bears -- not to mention each other. They didn't lie down and say "I'm too depressed to go on," -- and if any of their contemporaries did, they were weeded out of the gene pool. We were meant to thrive.
Since time immemorial, it was taken for granted that it was an individual's responsibility to develop the internal and external resources to deal with adversity. within the space of a lifetime, that belief has come to be regarded as utterly ridiculous, on a par with a belief in unicorns. What has happened to us?
http://open.salon.com/blog/xylocopa/2009/06/01/a_depressing_proposal
Really interesting discussion started here...some more thoughts from me:
Julie - sounds to me that your condition and diagnosis may actually be more along the lines of a brain-based diagnosis, as I allude to above. While depression and the action of drugs like SSRIs are not fully understood, I do think we know enough at this point to conclude a scientific basis exists for these conditions, and that drugs acting on those biochemical pathways can treat them or alleviate the symptoms. Glad you've found something that works well for you.
Patrick - I think if you look more closely at those studies, the placebo effect was in people with mild depression...anti-depressant drugs undoubtedly help many many people due to actual chemical effects in the CNS. Mild depression (perhaps some would simply call this unhappiness, but its definitely all relative) has been shown to be alleviated by non-pharmaceutical means as well...meditation, therapy, changes in life circumstances, etc, etc. But clinical depression (including those who are suicidal) is a very different thing. Also, there needs to be a distinction made between adult and youth pharmaceutical interventions for depression and related conditions.
I can't access the brain-based link above- it takes me to a password page, and I'd really like to read it, if you've got a more direct url.
Off topic, what do you think of Transcranial Magnetic Stimulation?
To quote your opening salvo in this post, my reaction is, "This is nuts!"
...
Psych!
*Ducks thrown copies of DSMs I-IV*
Seriously though, folks...if the DSM had any pretense of being a completely objective, scientific document, that vanished sometime in the last thirty-odd years, perhaps starting with the removal of homosexuality as a disorder.
I'm not against evolution and change of the manual; far from it (otherwise, I and many of my friends would be diagnosed as mentally ill because of who we date). As societies evolve and change, it's entirely appropriate to reassess our understanding of mental illness. )Bulemia, for example, is distressing and devastating, and to me seems deserving of treatment. )
It IS incumbent on the authors of the upcoming DSM to be aware of the cultural, social and commercial influences they operate under.
To pick just one example: "Several new diagnoses, including 'sexual interest/arousal disorder in women,' are proposed."
I'd be curious to know how those diagnoses are being written, and who is being consulted. The pharmaceutical industry in recent years has shown an interest in developing a female Viagra (so far, no luck). Simultaneously there has been at least one industry-sponsored conference on "female sexual dysfunction" that (from what I understand) took a fairly narrow focus (drug treatments).
I wonder what kind of influence this may have on the authors of DSM-V.
I'm not a conspiracy theorist. It's perfectly possible for the DSM-V authors to be completely ethical and yet influenced. "Social anxiety disorder" was known as "extreme shyness" until it was discovered that fluoxetine (Prozac) could help. Then it became a diagnosis. So it's possible that, if they are unaware of the currents that influence them, the DSM authors might create a diagnosis for sexual disorders in women that ignores the complex social and cultural factors that influence female sexual desire.
***
Fascinating post. It made me think much harder than I normally do on a weekend!
As for transcranial stimulation, that is a really interesting question! There have been several studies on these type of methods in recent years...I'll start working on a post about that (too long for a comment, I think!).
MediGeek - thanks for your thoughtful comments! I completely agree that the list of who writes these DSM entries would be important consumer information. The link to the APA's DSM-5 page above does contain some of that information...but of course it is not very user-friendly!