PUTNEY — As the new revision of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) nears completion, it seems certain that we will be seeing more and more news stories about changes in how we diagnose psychological disorders in the United States.
I pay attention to this issue because I work with college students with learning differences, and in the past decade the DSM has come to play a central role in many of their lives.
But I think all of us need to pay attention.
In the past weeks, stories have broken that the diagnosis of Asperger Syndrome might be eliminated and that the diagnosis of depression might be greatly broadened to include individuals who are sad because they have lost a loved one.
Recently, one opinion piece in The New York Times questioned the basic premise of the DSM, while another raised significant concerns about the treatment of attention disorders with stimulant medications.
In the revision of the DSM, a host of other changes are projected as well, including new disorders - shopping addiction and Internet addiction, for example - and shifts in how currently recognized disorders are understood and identified.
This topic might seem obscure or even arcane, a technical matter without much import for the rest of us. The opposite is true.
Psychiatry and the pharmaceutical industry that supports it are huge businesses in the United States. Last year, doctors prescribed more than millions of separate prescriptions of antidepressant medication. About 10 percent of schoolchildren already take stimulant medication to help them sit still and focus in class.
Changes in the DSM are likely to have ramifications and implications for nearly everyone.
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Unlike diagnosis in physical medicine, which is based on the assumption that there are underlying physiological causes for various illness, the DSM does not presume an underlying theory. It provides lists of symptoms and differentiating conditions, such as frequency, age of onset, and so on.
Actual diagnosis is based on the observations and data collected by psychiatrists. No blood tests or MRIs or X-rays will help us decide whether someone is normally sad or clinically depressed. It is a judgment call.
In my experience working with young adults with learning issues covered by the DSM, different therapists will often come up with very different diagnoses of the same set of symptoms.
It is also not unusual for me to meet a student who has several diagnoses at once: ADHD, obsessive-compulsive disorder, general anxiety disorder, and depression, for example. Some of these students are on a menu of several medications. When I was in college in the 1970s, this would have been unimaginable.
There is an important discussion under way about whether the DSM and the practices it supports do more good than harm. This discussion has not yet hit the mainstream media, but I expect that it will in the coming months.
One thing is for certain. Every time the DSM is revised - there have been four versions published since 1968, and this will be the fifth - the number of available diagnoses has increased and the amount of medication prescribed has grown almost exponentially.
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One side of the argument is that the DSM and its resulting medication-based approach to psychological challenges have brought help to countless sufferers who in past times were poorly treated and had poor outcomes. There is some evidence for this.
The other side of the argument is that we have translated normal human characteristics into medical problems, and that widespread use of medication has made things worse on the whole, rather than better.
Last summer, The New York Review of Books published a two-part review, “The Epidemic of Mental Illness: Why?” and “The Illusions of Psychiatry,” of three new books that challenge our DSM/medication approach.
One of the core points of this piece, based on The Emperor's New Drugs: Exploding the Antidepressant Myth, a meta-analysis of medication studies by Robert Kirsch, was that there is no hard evidence that antidepressants actually work, apart from a placebo effect: some patients get better because they think they have been given a pill that will make them better. The article's conclusion was that it is time to have a wholesale re-examination of our approach to psychological challenges.
A central contention of those who oppose the direction of the psychiatric profession is that it is largely driven by the interests of the pharmaceutical industry, the second-largest sector after oil. In this analysis, psychiatrists, many of whom receive consulting fees and other payments from drug firms, act as the sales arm for a booming capitalist enterprise.
This is a cynical view, one with which I have some sympathy, but I think a more nuanced analysis is possible.
Discourse communities like psychiatry - or any professional or academic discipline - are designed to be self-perpetuating. The allegiance between the medical profession and the pharmaceutical industry is inevitable; when it comes to the treatment of cancer, for example, it is impossible not to say that great things have come from the symbiosis.
As psychiatry developed a medical explanation for human differences in the 1980s and 1990s, and big pharma began to come up with new drugs based on refinements in brain science, it seems natural that an ever-expanding cycle of development was also created.
That does not mean it is a good thing, or that it is right, or that it is based on rigorous science. In the latter case, it clearly is not.
I was struck that some of the commentary opposing the elimination of Asperger's from the DSM focused on the fact that there is no pharmacological treatment for this neurological difference, which is marked by social awkwardness, difficulty with ambiguity, and often by intense interest and expertise in a fairly narrow area, as well as gifts in technology and science.
People with Asperger's often do very well academically and in careers, but they do benefit from extra supports - all of which cost a lot more than pills do, and none of which have an industry behind them.
I was also struck by the impression, reading articles about how normal grief might become a medical condition, that this direction was partly driven by the belief - I think a belief in good faith - that we should extend the benefits of anti-depressants to those who now suffer their mourning without medical intervention.
Nearly all of the proposed changes to the DSM are about new disorders that can be treated by existing drugs. For example, a change to the age of onset criteria for ADHD (from age 7 to age 12) could mean that millions more individuals will have access to Adderall and similar drugs if they struggle in school.
I have a bias here. I believe that medications should be the last resort, not the first, and that we should be very cautious before we re-categorize human differences as disorders.
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I have worked with young adults with learning differences for more than two decades, and in that time I have seen a wholesale turn toward medication as a first resort, rather than something to be tried only when other interventions fail.
The students I work with now often seem more capable and more engaged than those in past generations - there is a lot of good to be said about the so-called Millennial Generation.
But they also seem to be far more challenged psychologically and emotionally than ever before, and the central role that medication often plays in their lives seems extraordinary to me.
I can't say for certain, of course, that the great expansion of psychiatry and medication is making my students sicker, but something seems to be.
As the revision of the DSM nears completion and the news coverage continues, I think it is vital that we ask whether this work is meeting the basic principle of the medical profession: to first do no harm.