Will Anyone Get Through Life Without a Mental Disorder? By: Gary Schwitzer | July 22, 2010
http://tinyurl.com/278jkfb
There's a noteworthy column in Psychiatric Times, "Normality Is an Endangered Species: Psychiatric Fads and Overdiagnosis," by Allen Frances, MD.
He was chair of the task force that worked on the Diagnostic & Statistical Manual -- DSM-IV -- one edition of the "bible of psychiatry."
He is professor emeritus of psychiatry at Duke University School of Medicine.
There's a lot of common ground between what Dr. Frances writes and what Dr. Daniel Carlat (subject of my blog posting yesterday) writes about.
Dr. Frances is concerned about the directions that might be taken in the authoring of DSM-5 -- now underway.
Excerpts:
"Fads in psychiatric diagnosis come and go and have been with us as long as there has been psychiatry.
The fads meet a deeply felt need to explain, or at least to label, what would otherwise be unexplainable human suffering and deviance.
In recent years the pace has picked up and false "epidemics" have come in bunches involving an ever-increasing proportion of the population.
We are now in the midst of at least 3 such epidemics -- of autism, attention deficit, and childhood bipolar disorder.
And unless it comes to its senses, DSM-5 threatens to provoke several more (hypersexuality, binge eating, mixed anxiety depression, minor neurocognitive, and others).
Fads punctuate what has become a basic background of overdiagnosis.
Normality is an endangered species. The National Institute of Mental Health estimates that, in any given year, 25 percent of the population (that's almost 60 million people) has a diagnosable mental disorder.
A prospective study found that, by age thirty-two, 50 percent of the general population had qualified for an anxiety disorder, 40 percent for depression, and 30 percent for alcohol abuse or dependence.
Imagine what the rates will be like by the time these people hit fifty, or sixty-five, or eighty.
In this brave new world of psychiatric overdiagnosis, will anyone get through life without a mental disorder?
....
The "epidemics" in psychiatry are caused by changing diagnostic fashions -- the people don't change, the labels do.
There are no objective tests in psychiatry -- no X-ray, laboratory, or exam that says definitively that someone does or does not have a mental disorder.
What is diagnosed as mental disorder is very sensitive to professional and social contextual forces.
Rates of disorder rise easily because mental disorder has such fluid boundaries with normality.
....
The media feeds off and feeds the public interest in mental disorders. This happens in two ways.
Periodically, the media becomes obsessed with one or another celebrity whose public meltdown seems related to a real or imagined mental disorder.
The mental disorder is then endlessly commented on and dissected by the media.
The latest example is the Tiger Woods media frenzy which will likely lead to an "epidemic" of "sexual addiction."
...
There is no objective way to determine what should be the proper rate of mental disorder in the general population.
My view is that DSM-IV is almost certainly overinclusive, but I would not recommend tightening the criteria until we have clear evidence this would do more good than harm.
The DSM-5 bias to thrust open the diagnostic floodgates is supported only by flimsy evidence that does not come close to warranting its great risks of harmful unintended consequences.
It is too bad that there is no advocacy group for normality that could effectively push back against all the forces aligned to expand the reach of mental disorders."
4 Comments
July 23, 2010 Re: comments of l.burns.
Diagnosis required for payment of psychiatric services when no clinical diagnosis exists hmmm. Sounds like a job for counsellor and not an MD.
Doesn't the managed care company provide that service, and if not, should they not be compelled to by an esteemed psychiatrist who treats under contract?
Perhaps the lack of a real DSM-IV diagnosis should give pause to why they are in the office.....
-- Posted by thomas mccloskey pharmd
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July 23, 2010 Excellent article and comment. No diagnosis, no payment.
But diagnosis leads to payment AND a drug.
Don't underestimate the ingenuity of big pharma to create a diagnosis that can be "treated" with a patented molecule.
-- Posted by Ricker Polsdorfer MD
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July 23, 2010 I believe that the underuse of the diagnostic tests that do exist, and the tendency to allow patients to present after diagnosising themselves without careful consideration, reveals a kind of professional lassitude in treating mental illness.
The DSM not withstanding, as professionals we are able to use the NOS codes IF we take the time to.
It is especially interesting to me that we actually allow technicians and nurses without advanced training beyond a B.S. to make diagnositic evaluations that can remain in a chart.
Combine this with the Narsissism of some professional to diagnose "off the hip".
(I once actually heard a Psychiatrist say that if a patient reported difficulties tolerating the tags in clothes he knew they had Autism). Chilling.
Yes, we are required to have a diagnosis for insurance reimbursement.
For serious clinicians this is not a burden, but rather the usual part of a initial interview.
I believe that we should consider the model that the MD's are taking with the prescribing of antibiotics.
Not all patients that want this treatment receive it... Perhaps consider that the patient has an adjustment disorder first, and take our time.
Insurance companies allow this.
-- Posted by leslie macbride
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July 23, 2010 I believe that the major problem in diagnosis is caused by the Insurance Industry who prohibits Normality and does not pay for prevention. As a psychologist who accepts managed care, I am bound to come up with a DSM-IV diagnosis or no pay. LRB
Posted by l. burns
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