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The American Psychiatric Association (APA) published the first version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952. Its ongoing aim is to establish a common language and standard criteria for the classification of mental disorders. Since the APA published the fifth edition of the DSM in May 2013, there has been considerable criticism regarding its reliability and validity, cultural bias, overemphasis on signs and symptoms and underemphasis on the underlying causes of mental disorders. Is it just becoming a part of the growing trend in the medicalization of human nature?
Gary Greenberg, a practicing psychotherapist in Connecticut and contributing editor for Harper’s, recently published The Book of Woe: The DSM and the Unmaking of Psychiatry. He has established himself as one of the definitive voices on the failings of the mental health industry with his previous books, including Manufacturing Depression, and his many articles in The New York Times, The New Yorker, Wired, and other publications. Here, I interview Greenberg for Brain Blogger.
Lakhan: What’s new in the DSM-5?
Greenberg: There are some entirely new disorders listed, such as hoarding disorder and disruptive mood dysregulation disorder (DMDD). The former covers people who might previously have been diagnosed with obsessive-compulsive disorder, and who amass large quantities of worthless objects. Think of the recluse living in an old house so filled with newspapers, magazines and junk mail that there are only narrow aisles left. DMDD is a diagnosis intended for children prone to very angry outbursts well beyond the years in which tantrums are expected, and who show other difficulties in regulating their moods – extreme irritability, social withdrawal, etc.
Some diagnostic boundaries have been re-drawn. Notably, Asperger’s syndrome is now part of an autism spectrum disorder, for which the diagnostic threshold is set a little higher than it was. And it is now possible to be diagnosed with major depressive disorder as soon as two weeks after the loss of a loved one, something that was previously not allowed.
Lakhan: What benefits does the DSM offer any in terms of patient care, research, or billing?
Greenberg: The DSM provides the key to the health care treasury, whether you’re a person suffering from emotional distress and trying to get money from your insurance company for treatment, or a researcher trying to get a grant to study a particular mental problem. Without a diagnosis from the DSM, it is very difficult, if not impossible, to get the gatekeepers to release the funds. Some of this is changing; the National Institute of Mental Health, in part because of its disillusionment with the DSM’s diagnostic categories, is now funding research that is not tied directly to a DSM diagnosis. But the DSM remains the rainmaker for the mental health industry.
Lakhan: What are the downfalls of the DSM?
Greenberg: The biggest problem with the DSM, and the one everyone agrees on, is that none of its diagnostic categories are valid, i.e. there is no external verification for the conclusion that the set of behaviors and experiences that define a mental disorder is actually a disease in the same way that cancer or diabetes are.
In this sense, the DSM is a map without a terrain, and as a result both treatment and research are often conducted on disorders that may not exist. Even serious mental illnesses like schizophrenia do not seem to have the kind of integrity that most medical disorders have, and especially lack the kind of biological markers we expect diseases to have. A DSM diagnosis is made entirely on the basis of symptoms and their significance in a person’s life. This is analogous to diagnosing a person with a painful sore throat with strep even in the absence of a throat culture, and then treating them for the strep. Conversely, a diagnosis of major depression – because we have no way of knowing if there is really such a thing as major depression – is like a diagnosis of chest pain. Even careful observation does not tell a doctor much that is definitive. And the state of our understanding of mental disorders and their causes in the brain is still very preliminary.
Lakhan: Where do you see the current state of the mental health industry?
Greenberg: The mental health industry is at a crossroads. Given the escalating costs of health care in general, and the disarray of psychiatric diagnosis (and treatment), psychiatrists will have to turn more and more to biological explanations for mental disorders, and because those explanations are not forthcoming, they will continue to have to make much out of little. We’ve already seen this happen with the explosion of antidepressant prescription in the last 20 years, much of which was based on a notion that depressed people were suffering from “biochemical imbalances” or “serotonin deficiencies,” neither of which is a valid explanation for depression (but is a good marketing strategy for the drugs).
On the other hand, those psychiatrists who resist the temptation to biologize mental suffering – and there are many – will be under increased pressure to show some evidence that their understanding and treatment of mental disorders is valid and effective. Measuring outcomes in this field has always been extremely tricky, and there are no new innovations that promise to make it any less so. In the meantime, more and more clinicians, psychiatrists and non-psychiatrists alike, are separating themselves from the insurance industry (and with it from the DSM) in order to pursue what drew them to the field in the first place: ministering to people’s suffering.
Lakhan: What can be done to improve it?
Greenberg: I think our limited mental health care resources ought to be devoted to the most serious mental disorders, and that as the scope narrows to this range, it should also deepen to encompass the social and environmental factors at play in those disorders: not only brain chemistry, but also poverty, the threat of climate change, systematic oppression, and so on. Those factors can (or should) be part of understanding and treatment, certainly as much as brain chemistry, but they have been woefully under-researched.
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