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June 3, 2013 The Problem With Psychiatry, the DSM, and the Way We Study Mental Illness

Psychiatry is under attack for not being scientific enough, but the real problem is its blindness to culture. When it comes to mental illness, we wear the disor ders that come off the rack. By Ethan Watters Imagine for a moment that the American Psychiatric Association was about to comp ile a new edition of its Diagnostic and Statistical Manual of Mental Disorders. But instead of 2013, imagine, just for fun, that the year is 1880. Transported to the world of the late 19th century, the psychiatric body would ha ve virtually no choice but to include hysteria in the pages of its new volume. W omen by the tens of thousands, after all, displayed the distinctive signs: convu lsive fits, facial tics, spinal irritation, sensitivity to touch, and leg paraly sis. Not a doctor in the Western world at the time would have failed to recogniz e the presentation. The illness of our age is hysteria, a French journalist wrote. Everywhere one rubs elbows with it. Hysteria would have had to be included in our hypothetical 1880 DSM for the exac t same reasons that attention deficit hyperactivity disorder is included in the just-released DSM-5. The disorder clearly existed in a population and could be r eliably distinguished, by experts and clinicians, from other constellations of s ymptoms. There were no reliable medical tests to distinguish hysteria from other illnesses then; the same is true of the disorders listed in the DSM-5 today. Pr actically speaking, the criteria by which something is declared a mental illness are virtually the same now as they were over a hundred years ago. The DSM determines which mental disorders are worthy of insurance reimbursement, legal standing, and serious discussion in American life. That its diagnoses are not more scientific is, according to several prominent critics, a scandal. In a major blow to the APA s dominance over mental-health diagnoses, Thomas R. Insel, director of the National Institute of Mental Health, recently declared that his organization would no longer rely on the DSM as a guide to funding research. The weakness is its lack of validity, he wrote. Unlike our definitions of ischemic hea rt disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on t he nature of chest pain or the quality of fever. As an alternative, Insel called for the creation of a new, rival classification system based on genetics, brain imaging, and cognitive science. This idea that we might be able to strip away all subjectivity from the diagnosis of mental illness and render psychiatry truly scientific is intuitively appealing. But there are a couple of problems with it. The first is that the science simpl y isn t there yet. A functional neuroscientific understanding of mental suffering is years, perhaps generations, away from our grasp. What are clinicians and pati ents to do until then? But the second, more telling problem with Insel s approach lies in its assumption that it is even possible to strip culture from the study of mental illness. Indeed, from where I sit, the trouble with the DSM both this o ne and previous editions is not so much that it is insufficiently grounded in biol ogy, but that it ignores the inescapable relationship between social cues and th e shifting manifestations of mental illness. It is true that the DSM has a great deal of influence in modern America, but it may be more of a scapegoat than a villain.PSYCHIATRY TENDS NOT TO learn from its

past. With each new generation, psychiatric healers dismiss the enthusiasms of their predecessors by pointing out the unscientific biases and cultural trends o n which their theories were based. Looking back at hysteria, we can see now that 19th-century doctors were operating amidst fanciful beliefs about female anatom y, an assumption of feminine weakness, and the Victorian-era weirdness surroundi ng female sexuality. And good riddance to bad old ideas. But the more important point to take away is this: There is little doubt that the symptoms expressed by those thousands of women were real. The resounding lesson of the history of ies and diagnostic categories shape the about what constitutes real dis-ease historian Edward Shorter, the symptoms mental illness is that psychiatric theor symptoms of patients. As doctors own ideas change from time to time, writes the medical that patients present will change as well.

This is not to say that psychiatry wantonly creates sick people where there are none, as many critics fear the new DSM-5 will do. Allen Frances a psychiatrist who , as it happens, was in charge of compiling the previous DSM, the DSM-IV predicts in his new book, Saving Normal, that the DSM-5 will mislabel normal people, promo te diagnostic inflation, and encourage inappropriate medication use. Big Pharma, he says, is intent on ironing out all psychological diversity to create a human m onoculture, and the DSM-5 will facilitate that mission. In Frances dystopian postDSM-5 future, there will be a psychoactive pill for every occasion, a diagnosis for every inconvenient feeling: Disruptive mood dysregulation disorder will turn t emper tantrums into a mental illness and encourage a broadened use of antipsycho tic drugs; new language describing attention deficit disorder that expands the d iagnostic focus to adults will prompt a dramatic rise in the prescription of sti mulants like Adderall and Ritalin; the removal of the bereavement exclusion from the diagnosis of major depressive disorder will stigmatize the human process of grieving. The list goes on. In 2005, a large study suggested that 46 percent of Americans will receive a men tal-health diagnosis at some point in their lifetimes. Critics like Frances sugg est that, with the new categories and loosened criteria in the DSM-5, the percen tage of Americans thinking of themselves as mentally ill will rise far above tha t mark. But recent history doesn t support these fears. In 1994 the DSM-IV the edition Franc es oversaw launched several new diagnostic categories that became hugely popular a mong clinicians and the public (bipolar II, attention deficit hyperactivity diso rder, and social phobia, to name a few), but the number of people receiving a me ntal-health diagnosis did not go up between 1994 and 2005. In fact, as psycholog ist Gary Greenberg, author of The Book of Woe, recently pointed out to me, the p revalence of mental health diagnoses actually went down slightly. This suggests that the declarations of the APA don t have the power to create legions of mentall y ill people by fiat, but rather that the number of people who struggle with the ir own minds stays somewhat constant. What changes, it seems, is that they get categorized differently depending on th e cultural landscape of the moment. Those walking worried who would have accepte d the ubiquitous label of anxiety in the 1970s would accept the label of depressio n that rose to prominence in the late 1980s and the 1990s, and many in the same group might today think of themselves as having social anxiety disorder or ADHD. Viewed over history, mental health symptoms begin to look less like immutable bi ological facts and more like a kind of language. Someone in need of communicatin g his or her inchoate psychological pain has a limited vocabulary of symptoms to choose from. From a distance, we can see how the flawed certainties of Victoria n-era healers created a sense of inevitability around the symptoms of hysteria. There is no reason to believe that the same isn t happening today. Healers have th eories about how the mind functions and then discover the symptoms that conform

to those theories. Because patients usually seek help when they are in need of g uidance about the workings of their minds, they are uniquely susceptible to bein g influenced by the psychiatric certainties of the moment. There is really no ge tting around this dynamic. Even Insel s supposedly objective laboratory scientists would, no doubt, inadvertently define which symptoms our troubled minds gravita te toward. The human unconscious is adept at speaking the language of distress t hat will be understood. WHY DO PSYCHIATRIC DIAGNOSES fade away only to be replaced by something new? The demise of hysteria may hold a clue. In the early part of the 20th century, the distinctive presentation of the disorder began to blur and then disappear. The s ymptoms began to lose their punch. In France this was called la petite hysterie. One doctor described patients who would content themselves with a few gesticulat ory movements, with a few spasms. Hysteria had begun to suffer from a kind of dia gnostic overload. By 1930s or so, the dramatic and unmistakable symptoms of hyst eria were vanishing from the cultural landscape because they were no longer reco gnized as a clear communication of psychological suffering by a new generation o f women and their healers. It is true that the DSM has a great deal of influence in modern America, but it may be more of a scapegoat than a villain. It is certainly not the only force at play in determining which symptoms become culturally salient. As Frances sugges ts, the marketing efforts of Big Pharma on TV and elsewhere have a huge influenc e over which diagnoses become fashionable. Some commentators have noted that shi fts in diagnostic trends seem uncannily timed to coincide with the term lengths of the patents that pharmaceutical companies hold on drugs. Is it a coincidence that the diagnosis of anxiety diminished as the patents on tranquilizers ran out ? Or that the diagnosis of depression rose as drug companies landed new exclusiv e rights to sell various antidepressants? Consider for a moment that the diagnos is of depression didn t become popular in Japan until Glaxo-SmithKlein got approva l to market Paxil in the country. Journalists play a role as well: We love to broadcast new mental-health epidemic s. The dramatic rise of bulimia in the United Kingdom neatly coincided with the media frenzy surrounding the rumors and subsequent revelation that Princess Di s uffered from the condition. Similarly, an American form of anorexia hit Hong Kon g in the mid-1990s just after a wave of local media coverage brought attention t o the disorder. The trick is not to scrub culture from the study of mental illness but to unders tand how the unconscious takes cues from its social settings. This knowledge won t make mental illnesses vanish (Americans, for some reason, find it particularly difficult to grasp that mental illnesses are absolutely real and culturally shap ed at the same time). But it might discourage healers from leaping from one tren dy diagnosis to the next. As things stand, we have little defense against such e nthusiasms. We are always just one blockbuster movie and some weekend therapist s w orkshops away from a new fad, Frances writes. Look for another epidemic beginning in a decade or two as a new generation of therapists forgets the lessons of the past. Given all the players stirring these cultural currents, I d make a sizable be t that we won t have to wait nearly that long.

http://www.psmag.com/health/real-problem-with-dsm-study-mental-illness-58843/

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