04/11/23

Guild Interests Behind DSM Diagnosis

Now in its 5^th edition, the DSM-5-TR, the text revision of the Diagnostic and Statistical Manual, was released in March of 2022. This happened to be the first update in almost ten years and it’s selling very well for the APA, the American Psychiatric Association. The paperback version, as well as the hardback and desk reference editions, are the top four best sellers in psychiatry for Amazon. Saul Levin, the CEO and medical director for the APA told Axios that the public has been dying to know more about mental illness. “I think what really caught the imagination was that we’re sitting at home now and looking to say, ‘Boy, I’m feeling depressed — let me now go and find out more about it.'”

It’s hard to tell from this quote if Dr. Levin’s comment was a reflection of APA sales data for impulse buys for the DSM-5-TR, but I doubt it. A quick look at the Amazon prices DSM-5-TR indicates the paperback edition sells for $110.76 and the hardcover for $174.90. The desk reference editions are more affordable at $49.14 and $59.99. A better explanation for its bestselling sales is the fact that psychiatry in the U.S. and increasingly around the world has been dominated by the DSM for the past 70 years. Wired Magazine said this so-called bible for psychiatry is used in prisons, hospitals, and outpatient clinics to diagnose patients, prescribe medications, dictate future treatment and to justify payment for these services.

Axios reported how mental health has gone mainstream, with younger workers demand it as an employee benefit. Ralph Lewis, a Toronto-based psychiatrist, said in Psychology Today that psychiatry is guilty of having oversold its ability to answer the problems of coping with life and regulating one’s emotions and behaviors. Life can be stressful and complicated, leaving people with a feeling they can’t cope. “Many assume that psychiatry has the answers to problems of coping with life and regulating one’s own emotions and behaviors.” The expectations are particularly intense on psychiatrists as medical specialists “who are designated as the ultimate gatekeepers for diagnosis of mental illnesses and, more broadly, mental disorders.”

Mental disorders are, by their very nature, difficult to define with specificity. Anxiety and depression are the most common reasons for seeking psychiatric help. There is much confusion among the general public, and even often uncertainty among psychiatrists, as to when to consider these experiences mental disorders: the diagnosis depends on severity, number of associated symptoms, degree of functional impairment, and persistence or recurrence. Unfortunately, psychiatric diagnostic classification systems and mental health awareness campaigns have overgeneralized the definition of mental illness.

Dr. Lewis said the tendency now is to pathologize everyday problems, labeling them as mental disorders. Here he referenced Saving Normal, by Allen Frances, a psychiatrist and the former chair for the DSM-IV. Frances said there should have been cautions in the DSM-IV warning about overdiagnosis and providing tips on how to avoid it. Professional and public conferences, and educational campaigns should have been organized to counteract drug company propaganda.

None of this occurred to anyone at the time. No one dreamed that drug company advertising would explode three years after the publication of the DSM-IV or that there would be the huge epidemics of ADHD, autism, and bipolar disorder—and therefore no one felt any urgency to prevent them. . . We missed the boat.

See “Medieval Alchemy” for more on Allen Frances and Saving Normal.

Dr. Lewis said the COVID-19 pandemic drove up the rates of anxiety, depression and several other mental disorders. Ironically, while the data are complicated, there does not appear to have been much of a rise in the actual rate of mental disorders. What seems to have happened is people’s perception they need psychiatric treatment increased. Although some of the increase represents people now seeking help for significant problems, there is also a phenomenon of these diagnoses being sought.

A diagnosis offers a person an explanation for their difficulties. It lets a person feel understood. It simplifies complexity, helping make sense of things and bringing a bit of order to the inexplicable and chaotic. It provides validation and legitimacy to one’s struggles, as well as sympathy, and it might offer justification for one’s shortcomings or behavioral difficulties. It also confers a sense of identity and group-belonging.

A diagnosis may deliver practical benefits such as sick leave, disability benefits, academic accommodations, and insurance coverage for therapy. Other factors include social media, the internet, and celebrity influence—think about the attention paid to Simone Biles when she withdrew from several events at the 2020 Summer Olympics. And don’t forget about pharmaceutical advertising—just ask your doctor. “In many ways, what we are witnessing is the success of, and unintended consequences of, years of mental health education and destigmatization campaigns.”

Not only does overdiagnosis lead to over-prescribing medications, it also trivializes severe mental illness. The CDC said more than 50% of Americans will be diagnosed with a mental disorder in their lifetime. One in five will experience a mental illness in a given year. “If everyone has a mental disorder, then no one does, and the concept of mental disorder becomes meaningless. It becomes harder for the people most in need of psychiatric services to access the already overloaded system.”

The CDC also stated there was no single cause for mental illness. Early adverse life experiences, the use of alcohol or drugs, feelings of loneliness or isolation as well as biological factors or ongoing chronic medical conditions like cancer or diabetes can contribute to the risk of mental illness. But psychiatry continues to press for the medical model of mental illness and it seems defending the legitimacy of DSM diagnosis goes along with it. This debate has continued without any real movement towards a resolution for the last fifty years.

Dr. Daniel Morehead lamented in “The DSM: Diagnostic Manual or Diabolical Manipulation?” that it would be hard to overstate the torrents of criticism because of the DSM. He said, “The DSM has been, and remains, the centerpiece of contemporary critiques of psychiatry.” Critics of the DSM were wrong. Psychiatry is not at odds with other medical specialties. “Psychiatry differs from them only in the sense that more of the diseases behind psychiatric syndromes lack full explication.”

This is not evidence of its inferiority, according to Morehead, rather it is evidence of the complexity of the human brain. The DSM is “simply the place where clinicians match diseases to treatments through the lens of medical syndromes—just like other doctors.” This seems to be the heart of the debate and the reason for the vigor with which psychiatrists like Dr. Morehead defend the medical basis of psychiatry and psychiatric diagnosis. In another article published around the same time, “Let’s End the Destructive Habit of Doubting Psychiatric Illness,” he said it is time to permanently retire the idea that mental illness may not be fully medical. It is a “pernicious and misleading idea” and he challenged all psychiatrists to no longer tolerate it—publicly or privately.

Dr. Morehead and others appear to recognize that psychiatry is facing an institutional crisis unlike anything it faced since David Rosenhan published “Being Sane in Insane Places” in the journal Science in 1973. Rosenhan has eight “pseudopatients” seek admission to twelve different psychiatric hospitals. Once admitted, they stopped simulating any symptoms of abnormality and waited to see how long it took before they were released. Their length of stay ranged from 7 to 52 days, with an average length of stay at 19 days. None of the pseudopatients were identified as such by hospital staff members; but other patients did.

For more on the Rosenhan study, see “A Censored Story of Psychiatry,” Part 1 and Part 2.

In their book, Psychiatry Under the Influence, Robert Whitaker and Lisa Cosgrove said the trustees of the APA called a meeting shortly after Rosenhan’s article was published. They lamented how the public did not view psychiatry as a medical specialty. The trustees recommended the formation of a task force that would define mental illness and become a preamble to publish the DSM-III. And they made Robert Spitzer the chair of the task force in 1974. Whitaker and Cosgrove said from that beginning, the APA trustees saw how creating a new diagnostic manual could also serve a guild interest.

Remaking psychiatric diagnoses could be part of a larger effort by psychiatry to put forth a new image, which, metaphorically speaking, would emphasize that psychiatrists were doctors, and that they treat real “diseases.”

By adopting the disease model and asserting that psychiatric disorders were illnesses, the APA addressed both its critics and its image problem. Whitaker and Cosgrove said this happened when the organization metaphorically put on a white coat and presented itself as a medical specialty. “This was an image that resonated with the public.” With hindsight, they said, it is easy today to see the ethical peril for the APA that arose when the DSM-III was published. While the APA had devised a new diagnostic manual that helped remake its image, “the peril was that the guild interests might now affect the story it told to the public about the nature of mental disorders, and the efficacy of somatic treatments for them.”

In an interview for Medscape in 2020, the now former chair of the department of Psychiatry at Columbia and former president of the APA, Jeffery Liberman discussed “The Future of Psychiatric Diagnosis” and biomarkers with Melissa Arbuckle, also of Columbia University. She is the vice chair for education and training in the Department of Psychiatry at Columbia. Robert Spitzer, the architect of the DSM-III, was a Professor of Psychiatry at Columbia until his retirement in 2003.

Lieberman acknowledged at the start of the interview there have been no biomarkers identified yet in research. “For the entire history of our discipline, as long as physicians have studied mental illness, we have not had a diagnostic test for it. It’s a clinical diagnosis.” Nevertheless, he has faith that someday there will be a diagnostic test for mental illness: “I do believe that certainly within my professional lifetime, and hopefully sooner rather than later, we will see a diagnostic test.”

The APA self-consciously tied its fate to the DSM in the aftermath of the institutional crisis after the Rosenhan study. It seems to have done so at least partially to affirm itself as a legitimate medical specialty, with the power and authority to prescribe medications. As T. M. Luhrmann noted in Of Two Minds, “psychopharmacology is the great silent dominatrix of contemporary psychiatry.” Prescribing medications is what psychiatrists do that other mental health professionals cannot do. “And as mental health jobs become defined more by their professional specificity, more and more psychiatrists spend more of their time prescribing medication.”

The disease model of mental illness has been a tremendous asset in the fight against stigma and the fight for parity in health care coverage. And it is clear that the disease model captures a good measure of the truth. Mental illness often has an organic quality. People can’t just pull themselves back together when they are hearing voices or contemplating suicide, and their illness is rarely caused by bad parenting alone. Yet to stop at that model, to say that mental illness is nothing but disease, is like saying that an opera is nothing but musical notes. It impoverished us. It impoverishes our sense of human possibility. (Of Two Minds, p. 266)

11/16/21

If Not Psychiatry, What Then?

In June of 2021, the World Health Organization published a document, “Guidance on Community Mental Health Services.” The WHO document is seeking to provide quality care and support for person-centered, human rights-based and recovery-oriented mental health care and services worldwide. In a video launch of the event, Sir Norman Lamb said: “Our collective aim must be to end coercive practices, including seclusion and restraint, forced admission and treatment. And we must combat violence, abuse and neglect. This is an urgent imperative for all countries. It’s a global human rights priority.”

Reports from around the world highlight the need to address discrimination and promote human rights in mental health care settings. This includes eliminating the use of coercive practices such as forced admission and forced treatment, as well as manual, physical or chemical restraint and seclusion and tackling the power imbalances that exist between health staff and people using the services. Sector-wide solutions are required not only in low-income countries, but also in middle- and high-income countries.

The Executive Summary of the WHO report said global mental health services often face substantial restriction of resources, and operated with outdated legal and regulatory frameworks. There was an overreliance on the biomedical model, where the predominant focus of care was on diagnosis, medication and symptom reduction. Overlooked were the social determinants that impact people’s mental health, hindering progress towards a fuller realization of a human rights-based approach. “As a result, many people with mental health conditions and psychosocial disabilities worldwide are subject to violations of their human rights – including in care services where adequate care and support are lacking.” Key messages of the Guidance said:

According to the WHO Mental Health Atlas 2017, the global median government expenditure on mental health is less than 2% of total government health expenditure. In order to develop quality mental health systems with enough human resources to provide the services and provide adequate support of people’s needs, allocating adequate financial resources is essential. But the problems with mental health provision cannot be dealt with by simply increasing resources. “In fact, in many services across the world, current forms of mental health provision are considered to be part of the problem.”

The majority of existing funding is invested in the renovation and expansion of residential psychiatric and social care institutions. This represents over 80% of total government expenditure on mental health for low- and middle-income countries. “Mental health systems based on psychiatric and social care institutions are often associated with social exclusion and a wide range of human rights violations.” While some countries have taken steps towards closing psychiatric and social institutions, this action has not automatically led to dramatic improvements in care. The history of closing psychiatric hospitals in the U.S. illustrates this point.

The predominant focus of care in many contexts continues to be on diagnosis, medication and symptom reduction. Critical social determinants that impact on people’s mental health such as violence, discrimination, poverty, exclusion, isolation, job insecurity or unemployment, lack of access to housing, social safety nets, and health services, are often overlooked or excluded from mental health concepts and practice. This leads to an over-diagnosis of human distress and over-reliance on psychotropic drugs to the detriment of psychosocial interventions – a phenomenon which has been well documented, particularly in high-income countries. It also creates a situation where a person’s mental health is predominantly addressed within health systems, without sufficient interface with the necessary social services and structures to address the abovementioned determinants. As such, this approach therefore is limited in its consideration of a person in the context of their entire life and experiences. In addition, the stigmatizing attitudes and mindsets that exist among the general population, policy makers and others concerning people with psychosocial disabilities and mental health conditions – for example, that they are at risk of harming themselves or others, or that they need medical treatment to keep them safe – also leads to an over-emphasis on biomedical treatment options and a general acceptance of coercive practices such as involuntary admission and treatment or seclusion and restraint.

Reports from countries in all income brackets around the world highlight extensive and wide-ranging human rights violations that exist in mental health care settings. These violations include the use of coercive practices such as forced admission and forced treatment (as with Britney Spears), as well as manual, physical and chemical restraint and seclusion. In many services, people are exposed to poor, inhuman living conditions, neglect, and in some cases, physical emotional and sexual abuse. People with mental health conditions are also excluded from community life and discriminated against in employment, education, housing and social welfare. These violations further marginalize them from society, “denying them the opportunity to live and be included in their own communities on an equal basis with everyone else.”

A fundamental shift within the mental health field is required, in order to end this current situation. This means rethinking policies, laws, systems, services and practices across the different sectors which negatively affect people with mental health conditions and psychosocial disabilities, ensuring that human rights underpin all actions in the field of mental health. In the mental health service context specifically, this means a move towards more balanced, person-centred, holistic, and recovery-oriented practices that consider people in the context of their whole lives, respecting their will and preferences in treatment, implementing alternatives to coercion, and promoting people’s right to participation and community inclusion.

The End of Psychiatry as We Know it?

In Western society, this means challenging the biologically centered, medical model approach to psychiatry. Writing for Psychology Today, John Read noted how global critics of an overly biological approach to understanding and helping distressed people is often dismissed as radical or extremist. Critics of the dominant medical model approach, promoted by the drug companies and biological psychiatry, are often labeled as “anti-psychiatry.” However, Read replied, “We, however, view ourselves as anti-bad and anti-ineffective, unsafe treatments.” He then quoted Steven Sharfstein, then president of the American Psychiatric Association, who said in 2005:

If we are seen as mere pill pushers and employees of the pharmaceutical industry, our credibility as a profession is compromised. As we address these Big Pharma issues, we must examine the fact that as a profession, we have allowed the bio-psycho-social model to become the bio-bio-bio model.

Read also cited Robert Whitaker, who thought the WHO report was a landmark event. There is a global rethinking of how to treat and think about mental health. Whitaker said, “Model programs highlighted in this WHO publication, most of which are of fairly recent origin, tell of real-world initiatives that are springing up everywhere.” Read said it will be become harder for defenders of the medical model to dismiss organizations like the UN or the WHO as extremist, anti-psychiatry radicals. This can be illustrated by looking at how Psychiatric Times launched “Conversations in Critical Psychiatry,” a series of articles and conversations with prominent individuals who are critical of various aspects of psychiatry.

Dr. Awais Aftab, who is a psychiatrist, not only interviews other psychiatrists such as Dr. Ronald Pies, Dr. Giovanni Fava and Dr. Allen Frances, he also talks with individuals from the critical, so-called anti-psychiatry side of the debate, namely Dr. Joanna Moncrieff, Lucy Johnstone and Dr. Sami Timmi. His first interview in 2019 was with Dr. Frances, the Chair of the DSM-IV Task Force and a vocal critic of the DSM-5, over diagnosis and the state of mental health treatment in the U.S. Follow Drs. Frances and Aftab on Twitter to see what they have to say about the current state of psychiatry. One of the concerns for Dr. Fava has been how the psychiatric establishment uses the term “discontinuation syndrome” to describe “antidepressant withdrawal.” In “The Impoverishment of Psychiatric Knowledge,” he said:

If you teach a psychiatric resident that symptoms that occur during tapering cannot be due to withdrawal, he/she is likely to interpret them as signs of relapse and to go back to treatment (exactly what “Big Pharma” likes). In the UK, the NICE guidelines are changing to reflect the potentially malignant outcome with SSRI and SNRI discontinuation. I do not see anything similar happening in the US.

One of the staunchest defenders against so called anti-psychiatry has been Dr. Ronald Pies, professor emeritus of psychiatry, SUNY Upstate Medical University; and Editor in Chief emeritus of Psychiatric Times. Among the many articles Dr. Pies has written over the years defending establishment psychiatry and psychiatric practice are these on Psychiatric Times from the past year: “What Kind of Science is Psychiatry?”, “Do Psychiatrists Treat Diseases?,” and “Why Thomas Szasz Did Not Write The Myth of the Migraine.” He also wrote “Is Depression a Disease?”, about a report from the British Psychological Society whose central argument was that depression is best thought of as an experience rather than a disease; and “Poor DSM-5—So Misunderstood!”, which challenges the claim that the DSM-5 “offers a biomedical framing of people’s experiences and distress and impairment.”

In “The Battle for the Soul of Psychiatry,” Dr. Aftab and Dr. Pies talked about various issues he’s faced over his career. Dr. Pies agreed with Dr. Aftab that they could have done a better job of counteracting “the so-called ‘chemical imbalance’ trope.” Pies wished he had tackled that issue earlier than 2011. He acknowledged the field of psychiatry took a “fairly sharp turn” toward the biological from roughly 1978 to 1998, “which, to a considerable degree, persists to this day.” Dr. Pies thought the movement toward the biological/biochemical was heavily influenced by the pharmaceutical industry.

His hope for the future of psychiatry was to recover its pluralistic core. He said his department at SUNY Upstate Medical University emphasized the integration of psychopharmacology and psychotherapy, and explicitly endorsed “the biopsychosocial approach.” He supported constructive critics of psychiatry, whose aim was to improve the profession’s concepts, methods, ethics, and treatments. He rejected the “anti-psychiatry” critics, saying their rhetoric was clearly aimed at discrediting psychiatry as a medical discipline. This last charge by Pies seems to be true to a degree.

In their book, Psychiatry Under the Influence, Robert Whitaker and Lisa Cosgrove (two of the anti-psychiatry critics) said the time was ripe for a paradigm shift. Many Americans are seeking alternatives to psychiatry’s medication-centered care. Disagreeing with Dr. Pies, they believed psychiatry was facing a legitimacy crisis from a scientific standpoint. Second generation psychiatric drugs are no better than the first, belying the claim psychiatry is progressing in its somatic treatment of psychiatric diseases. “The disease model paradigm embraced by psychiatry in 1980 has clearly failed, which presents society with a challenge: what should we do instead?”

11/10/20

Does ‘Medical’ Mental Illness Exist?

A recent article in Vice, “The Movement Against Psychiatry,” wrestled with the ongoing debate between mainstream, institutional psychiatry and what has been called “anti-psychiatry” or critical psychiatry. The subtitle to the article was “The contentious debate of whether to fix—or completely overthrow—the way we treat mental illness.” Around the same time Mad in America highlighted an article published in the American Journal of Physical Anthropology, “Mental health is biological health.” The authors noted that while the biomedical sciences have rapidly reduced the global burden of infectious disease, mental disorders are emerging as major contributors to the global burden of disease. However, “the causes of most mental disorders … remain a mystery, and there has been little progress in reducing the prevalence of any of them.”

You get a condensed, but ultimately biased, picture of the debate, and are introduced to several of the individuals and institutions associated with anti-psychiatry in “The Movement Against Psychiatry,” whose author said anti-psychiatry should not be dismissed as a fringe movement. Issues like over-medication, and problems tapering off of meds are being seriously discussed within mainstream psychiatry. An interview series published in Psychiatric Times called “Conversations in Critical Psychiatry” seeks to engage “prominent individuals who have made meaningful criticisms of psychiatry and have offered constructive alternatives.” Awais Aftab, the author and interviewer for “Conversations in Critical Psychiatry”has interviewed several of the same individuals quoted and referred to in “The Movement Against Psychiatry”: Allen Frances, Sandra Steingard, Lisa Cosgrove, and Lucy Johnstone. Other individuals interviewed for “Conversations in Critical Psychiatry” include Joanna Moncrieff, Giovanni Fava, and Ronald Pies—names I recognized from my own journey and reading articles for and against “anti-psychiatry.”

In “Mental health is biological health,” you find a persuasive argument for a “re-thinking” of psychiatry from the ground up, including psychopharmacology and diagnosis. The authors said scientists understand little about the etiology of mental disorders and noted popular treatments like antidepressants and antipsychotics “have only moderate-to-weak efficacy in treating symptoms” and do not target biological systems that correspond to discrete psychiatric syndromes. The track record of biological psychiatry was said to be poor. “So far, there are no diagnostic tests, and treatments have limited efficacy.” Many critics believe this is due to fundamental flaws in the DSM classification system and that it is impeding research.

Unlike the natural classifications of plants, animals, infectious diseases, and inorganic substances, which all played key roles in the discovery of underlying causal principles, such as the theory of evolution, the atomic theory of matter, and the germ theory of disease, the various classifications of mental disorders have failed, so far, to uncover their underlying causes. The current system has little claim to be a “natural” classification, and is instead deeply contingent on the specific history of psychiatry.

Both articles are long, but worth reading and digesting, if you are interested in the topic. But first let’s push through some of the rhetoric. “The Movement Against Psychiatry” made a distinction between “anti-psychiatry” and “critical psychiatry” seeing anti-psychiatry as having more of an abolitionist sense—a movement of people who feel psychiatry is harmful and needs to be eradicated. Critical psychiatry may be a good lens to see how a biological paradigm has captured our cultural and medical understanding of mental distress. Lucy Johnstone said she agrees with many of the points made by critical psychiatry and opposes what she sees as the medical model of mental illness. She added the term anti-psychiatry is used in the U.K. as an insult.

Challenging the medical model of mental illness seems to be at the heart of the current debate over “anti-psychiatry.” Psychiatrists see their position as a medical specialty being attacked by so-called “anti-psychiatrists.” Aftab, who is a psychiatrist, warned that anti-psychiatry positions run the risk of encouraging distrust of the medical system and available treatment options. This leads people to be wary of seeking help. “For individuals who are on psychiatric medications, they can abruptly discontinue their medications with very serious consequences.”

On the other hand, “Critical psychiatry is more of a reformist movement, attempting to address psychiatry’s issues while maintaining some semblance of its infrastructure.” Lisa Cosgrove, a clinical psychologist and professor at the University of Massachusetts Boston, has a more nuanced view of psychiatry as a medical discipline. She said the fact that we don’t have biomarkers does not make psychiatry irrelevant as a medical discipline. “It just makes it different from other subspecialties in medicine.”

The failure to identify biomarkers for psychiatric illnesses under the auspicious of the medical model of mental illness, despite decades of research and millions of research dollars, stands in direct contrast to the progress with other medical specialties over the past 150 years. Psychiatry seems to feel uncomfortable or self-conscious of this difference.

In her article “Does ‘Mental Illness’ Exist?”, Lucy Johnstone said it obviously does exist, but the idea that the experiences subsumed under the term ‘mental illness’ are best explained as medical disorders “has never had any evidence to support it.” She said that despite decades of research, no so-called symptoms have been causally linked to established patterns of chemical imbalances, genetic flaws or other bodily malfunctions. “Any science – in this case medicine – needs to be able to demonstrate that it is based on a reliable and valid classification system, in order to develop testable hypotheses and hence the general laws that constitute a body of scientific knowledge.” If this cannot be established, she said the whole model breaks down and all psychiatry’s functions are fundamentally undermined. “In the words of Peter Breggin, psychiatry would then become ‘something that is very hard to justify or defend – a medical specialty that does not treat medical illnesses.’”

Johnstone said a psychiatric diagnosis turns ‘people with problems’ into ‘patients with illnesses.’ Psychiatry itself is a failed paradigm. While we have made extraordinary advances in what she called legitimate branches of medicine, “we have made no comparable progress in the illegitimate branch of medicine that calls itself psychiatry.” Her suggested starting point for understanding these problems was ‘formulation,’ the process in psychology of making sense of a person’s difficulties in the context of their social circumstances and life events. “The professional contributes their clinical experience and their knowledge of the evidence—for example, about the impact of trauma. The client or service user brings their personal experience and the sense they have made of it.”

In “Moving Beyond Psychiatric Diagnosis,” Awais Aftab interviewed Lucy Johnstone for his series, “Conversations in Critical Psychiatry.” He said he was intrigued by her envisioning formulation as an alternative to psychiatric diagnosis. He thought most people in psychiatry and psychology don’t see diagnosis and formulation as mutually exclusive, but rather as complementary and synergistic. “In fact, many would argue good diagnostic practice requires diagnosis to be made in the context of a formulation. Why should we see diagnosis and formulation as competitors rather than allies?” Johnstone replied:

The argument for psychological formulation—or formulation as an alternative to diagnosis—is simple. A formulation is a hypothesis, drawing on the best evidence, and tailored for the particular client. If you have a reasonably complete hypothesis, based on someone’s life experiences and the sense they have made of them, about why they are having mood swings or feeling suicidal or self-injuring, then you don’t need another, competing hypothesis that says, “And it is also because you have bipolar disorder/clinical depression/borderline personality disorder.” Even if we think these are valid categories, the diagnosis is now redundant.

Aftab disagreed that a diagnosis could be conceived as a causal hypothesis. He later asked her if she advocated for the abolition of psychiatric diagnosis. Johnstone said she did not think “abolition” was the right word. She believed they should use concepts that were evidence-based and jettison those that weren’t. Aftab responded by saying he thought it was disingenuous to argue that psychiatric diagnoses were not valid with respect to a certain scientific standard and then not apply the same standard to psychological formulations. But Johnstone was not distracted from her point.

She replied that in science, it was understood that constructs routinely had to be revised and then abandoned in favor of more accurate ones. She noted that in Biblical times, people believed madness was caused by evil spirits. No one could see them, but everyone was certain they existed. Diagnoses like schizophrenia were based on the same logic. “There are no bodily signs to confirm or disconfirm their presence, but we are convinced we’ll find them someday. This is purely a matter of faith, and it flies in the face of the mountain of evidence for psychosocial causal factors in all forms of mental distress.”

We may be able to come up with all kinds of cleverly nuanced perspectives on how we, as professionals and philosophers, understand psychiatric diagnosis, but the fact remains that people are being told they have mental illnesses and disorders, with all the usual connotations of those terms in Western societies. Moreover, they are heavily encouraged to take on the particular narrow understanding that you refer to—we are all bombarded with messages about “mental illness” being “as real as a broken arm”, and needing to be managed by drugs “just like diabetes.” Even the dubious compromise that is the “biopsychosocial” model—a way of acknowledging some role for psychosocial factors while at the same time instantly relegating them to “triggers” of a disease process—is not much in evidence on the ground. And furthermore, the biomedical message is reinforced by the fact that these labels are applied by doctors and nurses, working in hospitals and clinics, who use not just the labels themselves but the whole medicalized discourse of symptom, patient, prognosis, treatment, relapse, and so. The “stereotypical biomedical understanding of diagnosis” as you put it, is absolutely everywhere.

Aftab said clearly there was a lot wrong with the popular perception of what a diagnosis entails and he thought they needed tremendous effort to counter that. But he thought she was engaging in a certain sense with a strawman—a widespread stereotype of psychiatric diagnosis. If she was only trying to convince the public or professionals who did not have a nuanced understanding, her arguments worked well. But if her goal was to engage with thoughtful psychiatrists and psychologists, they were not sufficient.

Johnstone replied that her primary goal was to work towards a non-medical understanding of emotional suffering, which was what “mental illness” actually meant. She and her colleagues decided this was necessary because “there is not and never has been” any hard evidence that experiences that are now called “mental illness/disorder” were best understood in that way. There is an overwhelming amount of evidence that they arise from within the person and can be understood as a response to psychosocial adversities. “The dominance of the diagnostic viewpoint blinds us to the extent to which non-medical alternatives are already flourishing.”

In summary, it doesn’t matter whether you think I am putting forward a caricature of diagnosis. Diagnosis—however we choose to understand it—has no place in this field, and nor does the diagnostic thinking that it supports and perpetuates. All human experience has biological aspects, but not all forms of suffering are medical illnesses. We are dealing with people with problems, not patients with illnesses, and the whole paradigm—the “DSM mindset” as clinical psychologist Mary Boyle puts it—needs to change.

Notice another piece of rhetoric here: diagnosis itself is a medical term. So, the critique of psychiatric diagnosis has a medical nuance from the start.

Returning to “The Movement Against Psychiatry,” I agree that whether we are pro-psychiatry or anti-psychiatry resolving disagreements over the medicalization of ‘problems in living’ is complicated. After millions of dollars in research funding, biological psychiatry still finds the human brain to be an enigma. As Allen Frances said, “The human brain is the most complicated thing in the known universe and keeps its secrets well hidden.” Yet he thought the next right thing in care for the severely mentally ill was simple: decent housing; easily accessible treatment; social clubs; vocational rehab. The top priority was to get people out of prison and off the streets; and provide them with proper community housing and care. “How can it be that the richest country in the world is most neglectful of its most vulnerable citizens?”

It’s nearly as useless to be steadfastly pro-psychiatry as it is to be anti-psychiatry. Psychiatry is not a monolith, but an entire field and history, with some practices that are more helpful than others, and a huge range of diversity in terms of the kinds of people it treats.

Can’t we start with a critical psychiatry approach and see where it leads us? Calling for the abolition of psychiatry or diagnosis only results in the further entrenchment of psychiatry and supporters of the medical model with no real change to the existing system. Attempts at dialogue, as with Dr. Aftab’s interviews for “Conversations in Critical Psychiatry” and the formation of groups like CEP, Council for Evidence-Based Psychiatry, and the Critical Psychiatry Network are a good start.

12/10/19

Patients Deserve Better Than the DSM

Even before the fifth edition of the DSM was published in 2013 there were serious critiques of its reliability and validity. The then Director of the National Institute of Mental Health (NIMH), Thomas Insel, said it was at best, “a dictionary, creating a set of labels and defining each.” He went on to say its strength was its reliability, meaning it provided a way for clinicians to use the same terms in the same way. Its weakness was that it lacked validity. “Patients with mental disorders deserve better.” However, two weeks later, in a joint press release, Insel and the President-elect of the American Psychiatric Association, Jeffrey Lieberman, issued a statement. They said the NIMH had not changed its position on DSM-5. The DSM and the International Classification of Diseases-10 (ICD-10) remain “the contemporary consensus standard for how mental disorders are diagnosed and treated.”

The NIMH had developed a new research strategy to classify mental disorders based upon “dimensions of observable behavior and neurobiological measures,” known as Research Domain Criteria (RDoC). The project was to “transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system.” RDoC was described as the framework for collecting data to formulate a new nosology. Insel said they realized they could not succeed if they used DSM categories as the “gold standard,” so the NIMH would be “re-orienting its research away from DSM categories.” Yet Insel emphasized for now, RDoC was merely a research framework, not a clinical tool.

The situation has not changed much in the past six years. RDoC is still a research framework and the DSM-5 is still “the best information currently available for clinical diagnosis of mental disorders.” Dissatisfaction with the DSM-5 and perhaps some impatience with the promises of RDoC, led Jonathan Raskin, a psychology professor at SUNY New Paltz, to ask, “What Might an Alternative to the DSM Suitable for Psychotherapists Look Like?” Raskin has been previously critical of the DSM-5, co-authoring a previous article, “DSM-5: Do Psychologists Really Want an Alternative?”

In “What Might an Alternative to the DSM Suitable for Psychotherapists Look Like?” Raskin said there seemed to be an uneasy relationship between psychotherapists and the medical model of the DSM diagnostic system they use. While more than 90% of psychologists and counselors say they use the DSM-5 they also expressed support for the development of an alternative. Writing for Mad in America, Jessica Janze quoted him as saying:

By seeing human suffering as a function of broken brains, the DSM often overlooks the complex and mutually determining interplay of psychological, sociocultural, contextual, and biological factors … While the DSM does not completely ignore psychosocial factors, it typically treats them as extraneous variables that influence, but are distinct from, the presumed primary cause of emotional suffering: a dysfunction inside the individual.

Raskin was skeptical of RDoC, saying the approach was misguided, because “it may not be possible to diagnose and explain all forms of human suffering in terms of underlying biological processes.” This wasn’t to say biology was irrelevant. “Psychological, social, and contextual factors influence biology just as much as biology influences them.” An alternative manual should contain five elements:

Psychosocial factors are placed on equal footing with biological factors;
It must categorize problems, not people;
It must be scientifically grounded;
It must be collaboratively developed;
It must be usable across orientations, professions, and constituencies.

In “Heterogeneity in Psychiatric Diagnostic Classification,” Allsopp, Read and Corcoran analyzed five key chapters of the DSM-5 on ‘schizophrenia’, ‘bipolar disorder’, ‘depressive disorders’, ‘anxiety disorders’ and ‘trauma-related disorders.’ It was created to provide a common diagnostic language for mental health professionals and provide a definitive list of mental health problems, along with their symptoms. But the authors found that the psychiatric diagnoses all used different decision-making rules to codify the respective lists and their symptoms. There was a significant overlap of symptoms between diagnoses. And they told little about the individual patient and what treatment they needed. Neuroscience & News Research said: “The authors conclude that diagnostic labeling represents ‘a disingenuous categorical system.’”

Kate Allsopp said while the diagnostic labels created the illusion of an explanation, “they are scientifically meaningless and can create stigma and prejudice.” She hoped their findings would encourage mental health professional to think beyond diagnoses and consider other explanation of mental distress. Peter Kinderman said the study provided more evidence the biomedical diagnostic approach in psychiatry is not fit for its purpose. “Diagnoses frequently and uncritically reported as ‘real illnesses’ are in fact made on the basis of internally inconsistent, confused and contradictory patterns of largely arbitrary criteria.” It seems to assume all distress results from disorder, and relied heavily on “subjective judgments about what is normal.” Professor John Read concluded: “Perhaps it is time we stopped pretending that medical-sounding labels contribute anything to our understanding of the complex causes of human distress or of what kind of help we need when distressed.”

The Superior Health Council of Belgium published “DSM(5): The Use and Status of Diagnosis and Mental Health Problems” in June of 2019. The Report said there were several problems with the DSM and ICD and they recommended both be used with caution. DSM categories should not be at the center of care planning. At a clinical level, classifications do not provide a picture of symptoms, nor do they help manage needs and prognosis, “because they lack validity, reliability and predictive power.”

From an epistemological point of view, classifications are based on the assumption that mental disorders occur naturally, and that their designations reflect objective distinctions between different problems, which is not the case. The boundaries between people with a disease and those who are free from it are more dimensional than categorical.

The Report recommended a “multi-layered” diagnostic process, starting with a narrative description of the individual’s symptoms. These symptoms should then be re-contexualized, classifying them on the basis of a limited number of general syndromes. And finally, they should discuss these symptoms in terms of a continuum from crisis to recovery in order to assess the need for care, the level of crisis and the recovery perspective. Diagnoses should remain as working hypotheses and DSM and ICD use should be limited to broader categories of disorders. “Disorders should not be considered as a static characteristic, but rather as interactive.” Diagnostic labels should be used with caution.

It seems psychiatry is facing another crisis like that which occurred in the 1970s with Rosenhan’s classic “Being Sane in Insane Places.” Critiques of the validity and reliability of the most recent edition of the DSM have not faded and seem to be gaining more credibility. The Superior Health Council of Belgium said the diagnostic labels of the DSM-5 lack predictive power and should be used with caution. Yet it is “the contemporary consensus standard for how mental disorders are diagnosed and treated.” Paraphrasing the words of Thomas Insel: “Patients with mental disorders deserve better” than the DSM.

For more on concerns with psychiatric diagnosis, the DSM-5 and RDoC on this website, try: “The Quest for Psychiatric Dragons, Part 1,” “The Quest for Psychiatric Dragons, Part 2,” “Psychiatry Has No Clothes” and “Psychiatry’s Mythical Phoenix.”

02/24/17

Misdiagnosing Substance Use

Allen Frances doesn’t like the DSM-5 and you can hear him say so here. He said our mental health system was in a mess. And he is afraid that with DSM-5, it will get even worse. “People who are essentially normal are being diagnosed with mental disorders they don’t have.” Small changes in the diagnostic system can result in tens of millions of normal people qualifying for a diagnosis. He used himself as an example, stating how he would qualify for several of the DSM-5 disorders. Typical symptoms of grief over his wife’s death, lasting beyond two weeks, would have signified him as having a Major Depressive Disorder.

Anther mistake was combining what had been two different diagnoses of substance use in the DSM-IV—Substance Abuse and Substance Dependence—into one: Substance Use Disorder. Substance Abuse was when someone had recurrent, but intermittent, trouble from recreational binges. Substance Dependence was a continuous and compulsive pattern of use, often with tolerance and withdrawal. The majority of substance abusers “never become addicted in any meaningful sense.”

The two DSM IV diagnoses have radically different implications for treatment planning and for prognosis. Artificially lumping them together in DSM-5 forces inaccurate diagnosis, loses critical clinical information, and stigmatizes as addicts, people whose substance problem is often temporary and influenced by contextual and developmental factors.

Hasin et al., “DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale,” presents the rationale used by the DSM-5 workgroup for substance use disorders for its changes, particularly combining abuse and dependence into one disorder. They recommended the combination as well as dropping one diagnostic criteria (legal problems) and adding one (craving). Two criteria are required to diagnose a Substance Use Disorder. The number of criteria met will indicate mild (2 to 3 criteria), moderate (4 to 5), and severe disorders (6 or more). The following chart, taken from the article, illustrates the changes from DSM-IV to DSM-5.

Frances is not alone in seeing value with two distinct types of substance use disorder. Carleton Erickson in The Science of Addiction noted how the distinction allowed for the differentiation between individuals with drug-related problems who could stop using when they wished (substance abusers), and others who had the disease of chemical dependence. Chemically dependent people have a dysregulation of the mesolimbic dopamine system and generally cannot stop using drugs without intensive intervention into their drug use problems. “According to these criteria, drug abuse in intentional, ‘conscious,’ or voluntary. Drug dependence is pathological and unintended.”

In his article, “DSM-5 Made a Mistake Eliminating Substance Abuse,” Allen Frances indicated the DSM-5 workgroup for substance use disorders based its rationale for dropping Substance Abuse on studies suggesting the distinction was hard to make. He said the results of the studies were not definitive. Moreover, their interpretation was flawed by what he said was a basic DSM-5 misunderstanding of the nature of psychiatric diagnosis. “All DSM disorder overlap with other DSM disorders and also frequently with normality.” Fuzzy boundaries among near diagnostic neighbors are common and not a sufficient excuse to collapse clinically valuable distinctions.

Carleton Erickson’s discussion of the degrees of severity with drug problems helps to illustrate this misunderstanding. He indicated there were mild, moderate and severe forms of both drug abuse and drug dependence. Most people don’t think in terms of severity with substance use problems. You either have a problem or you don’t; you either abuse drugs or you don’t. He then illustrated their relationship to drug-seeking behavior as follows.

Drug Abuse	Drug Dependence	Drug-Seeking
Mild		Little/None
Moderate		Some
Severe	Mild	A Lot
	Moderate	Even more
	Severe	All the Time

The overlap referred to by Frances occurs between severe drug abuse and mild drug dependence. The inability of psychiatric diagnosis to make a clear distinction here seems to have led to the decision to collapse the abuse and dependence diagnoses into one category in the DSM-5.

I think another overlap between drug abuse and drug dependence happens with regards to self-control. A distinction is necessary between self-control of thoughts, feelings and behavior when drinking and control of the drug intake itself. Any substance use can lead to a loss of self-control over an individual’s thoughts, feelings and behavior. When that loss of control results in recurrent, intermittent trouble, there is a drug abuse problem. The severity of this type of loss of self-control and the related intermittent trouble varies.

Not everyone who abuses a drug experiences the classic sense of losing of control over how much of the drug they use. A loss of control over drug intake—a continuous and compulsive pattern of use—is only evident within drug dependence. And again, the severity of this loss of control over drug intake varies. So I’d adopt Erickson’s degrees of severity with drug abuse and dependence problems as seen below.

Loss of Self-Control in Abuse	Loss of Control over Drug Intake in Dependence
Mild
Moderate
Severe	Mild
	Moderate
	Severe

A substance abuse problem with severe trouble related to loss of self-control may be indistinguishable from a substance dependence problem with mild loss of control over drug intake. Both people would look at their severe “trouble” and attribute it to drinking or drugging too much. Given an equal motivation to avoid further “trouble,” the substance abuser would likely have an easier time maintaining abstinence. Carleton Erickson said chemical dependence is not a “too much, too often, withdrawal” disease; it’s a “I can’t stop without help disease.” There is a pathological, compulsive pattern to substance use.

There does seem to be a “fuzzy boundary” between Substance Abuse and Substance Dependence. Nevertheless, the distinction still carries some clinical and diagnostic value. I agree with what Allen Frances said: “The change was radical, creates obvious harms, and provides no apparent benefit.” What should clinicians do? Frances suggested they simply ignore the DSM-5 change. He said it was appropriate and clinically preferable to continue making the distinction.

There is nothing sacred or official about the DSM-5 choices — I know because I made the choices for DSM-IV. The ICD coding system is official; the DSM codes are just one groups’ fallible adaptation of them. It is of great significance that the official coding in ICD-10-CM does not follow the DSM-5 decision to eliminate Substance Abuse. Instead, ICD-10-CM retains the DSM-IV terminology and continues to provide separate Substance Abuse and Substance Dependence codes for each of the major classes of substances.

The ICD-11 workgroup, currently in the final stage of development before field tests, will continue to separate Substance Dependence and Harmful Substance Use. The guidelines for dependence are revised and simplified into three diagnostic features: impaired control over substance use; increasing priority in life and physiological features. Severity qualifiers were suggested only for alcohol intoxication. They also introduced a new diagnostic category, with no equivalents in ICD-10 or DSM-5: single episode of harmful use. Frances commented:

The DSM-5 mistake thus places it out of line with ICD-10, ICD-11, previous DSM’s, and well established clinical practice. Clinicians remain truer both to clinical reality and to ICD coding when they ignore the new DSM-5 lumping of substance use disorders and instead continue to distinguish Substance Abuse from Substance Dependence. DSM’s are explicitly meant to be used only as guides, not worshiped as bibles. Clinicians are free to ignore DSM whenever it makes mistakes that go against clinical common sense and the International coding system.

Faith Seeking Understanding

Charles Sigler, D.Phil.

Tag: diagnosis