Sunday, July 11, 2010
Normality Is Now An Endandered Species.
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, DSM5 threatens to provoke several more (hypersexuality, binge eating, mixed anxiety depression,group thinking, worshipping celebrities, minor neurocognitive, and others
Fads punctuate what has become a basic background of overdiagnosis. Normality is an endangered species. The NIMH 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?
What accounts for the recent upsurge in diagnosis? I feel quite confident we can't blame it on our brains. Human physiology and human nature change slowly if at all. Could it be that the surge in mental disorders is caused by our stressful society? I think not. There is no particular reason to believe that life is any harder now than it has always been-more likely we are the most pampered and protected generation ever to face its inevitable challenges. It is also tempting to find environmental (eg toxins) or iatrogenic causes (eg vaccinations), but there is no credible evidence supporting either of these. There is really only one viable environmental candidate to explain the growth of mental disorder-the widespread recreational use of psychotropic substances. But this cannot account for the extent of the "epidemics," particularly since most have centered on children.
No. 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.
What are the most important contextual forces?
1. DSM-III made psychiatric diagnosis interesting and accessible to the general public. More than a million copies of each edition have been sold-more to ordinary people than to mental health professionals. The widespread appeal of the DSM is in its clear definitions that allow people to diagnose themselves and family members. For the most part, this has been a useful contributor to self-knowledge and to early identification and treatment. But it can also be overdone and inevitably leads to overdiagnosis in the hands of non-clinicians.
2. This interacts with the fact that it is fairly easy to meet criteria for one or another DSM diagnosis. The definitional thresholds may be set too low and the DSM system has included many new diagnoses that are very common in the general population. The experts who establish the DSM criteria always worry more about missing cases than about casting too wide a net and capturing people who do not require a diagnosis or a treatment.
3. The pharmaceutical industry has proven to be fairly unsuccessful in developing new and improved medications. But it is wonderfully effective at marketing existing wares and is an important engine in overdiagnosis and the spread of psychiatric epidemics. The drug companies are skilled at mounting a full-court press that includes "educating" doctors, "supporting" advocacy groups and professional associations, controlling research, and direct-to-consumer advertising.
4. Patient and family advocacy groups have played an important role in calling attention to neglected needs; in lobbying for clinical, school, and research programs; and in reducing stigma and promoting group and community support. There are times, however, when advocating for those with a disorder can spill over and promote the spread of the disorder to others who are mislabeled. The mental disorders all have unclear boundaries among themselves and with normality. Clinical experience and caution are necessary in distinguishing at the boundary who does and who does not meet the criteria for the diagnosis. Well-informed self-diagnosis or family diagnosis can play a screening role and is part of being a wise consumer. But self-diagnosis is usually far too inclusive and needs trimming and validation by a cautious clinician.
5. It is no accident that the recent "epidemics" have all occurred in the childhood disorders. There are two contributing factors. The first is the push by drug companies into this new market. The second is that the provision of special educational services often requires that there be a DSM diagnosis.
6. The internet is a wonderful communication tool that provides a wealth of information and creates a social network of informed consumers. But it can also contribute to the spread of "epidemics". Disorder-focused Web sites (often run by patients and families) provide a powerfully attractive forum and support system that draws people who may inaccurately selfoverdiagnose in order to be part of the internet community.
7. 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." Popular movies can also be contagious. Sybil helped cause a fad in multiple-personality disorder.
8. We live in a society that is perfectionistic in its expectations and intolerant of what were previously considered to be normal and expectable distress and individual difference. What was once accepted as the aches and pains of everyday life is now frequently labeled a mental disorder and treated with a pill. Eccentrics who would have been accepted on their own terms are now labeled as sick (with Asperger's) and in need of therapeutic intervention. Mental disorder labels can provide cover for societal problems. Criminal behavior has been medicalized (eg, rape as a psychiatric disorder) because prison sentences are too short and such labeling allows for indefinite psychiatric commitment.
All the above factors interact to produce follow-the-leader diagnostic fads that punctuate a general pattern of overdiagnosis. The definition of fad is "a temporary fashion, notion, manner of conduct especially one followed enthusiastically by a group." What makes something a psychiatric fad is that a psychiatric label seems to explain some common, nonspecific, problematic symptom or behavior, and that label is suddenly given to everyone. The fact that everyone is doing it reduces the stigma of the diagnosis and leads to more people getting the diagnosis. Then, like the old adage that if you have a hammer, everything looks like a nail, the new label gets twisted to fit cases which really don't fit it simply because the label itself is popular and accepted.
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.