As the diagnostic process defining mental disorders evolves so does the complexity embedded in competing theories of the mind and what it means to be human. How the mind works and what soul entails remain in large part a mystery to us. We can’t escape what we don’t know as we struggle to find out who in fact has a psychiatric diagnosis and why. Add to the challenge of discovering why we suffer and when we cross a diagnostic threshold into pathology the fact that we live in a market economy where treatment is linked to dollars. So we have competing agendas, forces, egos, legitimate and perceived fears and anxiety, the literal and financial survival of individuals and industries at play here. Read more…
I comment on the field of mental health and the psychiatric diagnostic model from a systems management/analysis perspective. Katy comes at it from an in the trenches approach as a licensed marriage and family therapist (LMFT) and investigator (PI) and as a social worker who witnesses how mental health services are delivered, taking a toll on individuals and families. I have contended for some time that only psychiatrists are qualified to give psychiatric diagnoses because of the level of their clinical training combined with a medical background. Over time as more mental health professionals like licensed clinical psychologists and marriage and family therapists, as well as primary care physicians, have become drivers in providing a psychiatric diagnosis the diagnostic process itself has been severely compromised. Read more…
Reactions are coming in on the release of a draft of the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-V), which is due to be published in 2013. We posted one of the changes in the manual that officially puts Asperger’s syndrome in the autism spectrum. There’s already lots of great analysis on the changes to come for diagnosing psychiatric disorders. We will continue tracking what others are saying about the DSM-V and how these changes will impact the ways we are named and treated. For now, two articles about the DSM-V draft which stand out are from Mind Hacks titled “The draft of the new ‘psychiatric bible’ is published” and the NYT titled “Revising Book on Disorders of the Mind.” here is an excerpt from the Mind Hacks post:
A new child diagnosis of Temper Dysregulation Disorder with Dysphoria has been added. If this seems unremarkable it’s actually big slap in the face for a small but vocal group of US psychiatrists who have been pushing the idea of ‘child bipolar disorder’ – arguing that sad children who have tantrums are showing a juvenile form of ‘manic depression’.
This has become popular, almost entirely in the US, and has led to the alarming rise in children taking antipsychotics. The LA Times reports that this new diagnosis has been created in large part to stop kids being diagnosed with child bipolar. That’s the slap.
and from the NYT article:
One of the most controversial proposals was to identify “risk syndromes,” that is, a risk of developing a disorder like schizophrenia or dementia. Studies of teenagers identified as at high risk of developing psychosis, for instance, find that 70 percent or more in fact do not come down with the disorder.
“I completely understand the idea of trying to catch something early,” Dr. First said, “but there’s a huge potential that many unusual, semi-deviant, creative kids could fall under this umbrella and carry this label for the rest of their lives.”
Here is a list of posts on the DSM-V draft release:
(Find the illustration above here.)
With a background in organizational systems and management, focusing on mental heath systems in particular and how they affect our understanding of ourselves (identity), others, and the world around us, I track the progress and complications associated with the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM is thought of as the Bible of the mental health industry. It is interesting, however, that when I have talked to a significant number of licensed mental health professionals throughout the years they tell me they don’t really adhere to much of the DSM when treating their patients other then for the purpose of providing a diagnosis for insurance providers. The DSM is tied intimately to how clinicians get paid, which I have always found problematic because it can lead to fitting clients into categories that are not necessarily where they belong. Funding (money) is the great driver of any industry and the mental health field is no exception.
I have tried to walk a fine line of not negating much of the good work that is going on in the mental health field and diagnostic psychiatry/psychology, but also assessing where this field is not working as well. Part of this focus, as frequently noted, has been on the broad net being cast across our culture to diagnose so many of us with mental health disorders. This process of diagnosing and then medicating categories/tribes of people is not only an effective marketing/business model it also has an enabling affect, making us think, perceive, and feel that we are sicker then we in fact are. We are all given a diagnostic reason and label for why we can’t cope rather then distinguishing who in reality has a true psychiatric disorder. Treating less of us is not as lucrative. Read more…
The Foundation for Psychocultural Research (FPR) has posted an upcoming conference titled “Cultural and Biological Contexts of Psychiatric Disorder Implications for Diagnosis and Treatment.” Read more…
Our Other Bible: The Diagnostic and Statistical Manual of Mental Disorders (DSM) Digs Deeper Into Our Lives
It has been since 1994 that the last major revision/edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) was published, further shaping our sense of identity in terms of “mental health.” For the past almost six decades when the DSM was first published in 1952 this manual has taken hold of our national psyche in the way we think and talk about ourselves and others. As I have asked before on this blog and in numerous conversations with others “How sick are we?”
My question is based in observations, experiences and research over a lifetime where people are using psychiatric diagnostic language to describe themselves and others without the training and education that is necessary to understand these complex mental health diagnostic equations. Even when someone has training, education and experience as a psychiatrist, psychologist and therapist he or she does not always get it right when it comes to diagnosing and treating a person who is considered to be “disturbed.” The hit and miss ratio that comes with the DSM model should cause all of us to be more humble and cautious when it comes to labeling others with psychiatric disorders.
The next revision of the DSM is due to come out in 2012. The website medpageToday has posted a preview of some of the expected changes in terms of diagnoses and process titled “APA: Major Changes Loom for Bible of Mental Health.” You can check out what the American Psychiatric Association (APA) has to say about these changes in their post titled “DSM-V: The Future Manual.”
Despite its many flaws the DSM model is a part of our lives and has tremendous value if used wisely. For this reason, we have to leave its language and diagnostic process to the professionals. This does not mean when seeking help for ourselves, family and friends that we do not question the authority of this manual in our lives. The first thing we want when trying to find help is an answer for why we or someone else is disturbed. As noted in a post by John M. Grohol, Psy.D. onPsychCentral titled “Update: DSM-V Major Changes,” the DSM V is adjusting once again to the complexity of diagnosing individuals. The APA will take the categories of different disorders, each having its own set of specific behaviors and symptoms, and begin what they are now calling “dimensional assessments” of disorders. This adds another layer of complexity and nuance to an already difficult diagnostic process.
Here is an excerpt from the medpageToday post “APA: Major Changes Loom for Bible of Mental Health:”
Schizoaffective disorder and gender identity disorder are among those that may be on the chopping block, according to members of the working groups leading the revision who spoke here at the American Psychiatric Association annual meeting.
Perhaps more significantly, they said, DSM-V is likely to include dimensional assessments in addition to the familiar symptom checklists from past versions of the “psychiatrist’s bible.”
The most significant change proposed has to do with the inclusion of dimensional assessments for depression, anxiety, cognitive impairment and reality distortion that span across many major mental disorders. So a clinician might diagnose schizophrenia, but then also rate these four dimensions for the patient to characterize the schizophrenia in a more detailed and descriptive manner.
The questions then become for me as a systems analyst; how will these changes affect the understanding of disorders for those who are applying the diagnostic model, and how will the depth of training and education that are necessary to successfully apply these new standards translate into their practice? Is what we need more dimensional complexity in the diagnostic process or more clarity and simplicity when it comes to defining and deciding who is in fact disturbed and in need of this level of help.
As I have said before I think the larger problem is that we are creating a cultural dynamic where too many of us are being convinced that we are disturbed and in need of a label and treatment. This dynamic is troublesome on many levels, particularly in terms of the amount of resources and time that is spent on those who do not need this kind of help. The focus should be on those who cross the pathological threshold where they can no longer function effectively in terms of taking care of themselves, maintaining relationships and being productive in their work.
I do think that professionals need a shared and common referent in the form of a language and specific diagnostic process with well established standards of practice. The reality is that the DSM is with us and accepted as the way we define who is suffering from a psychiatric condition which requires treatment. But, those practicing this dark difficult art must remain aware of its limitations, as well as their own, and in reverence to what we still do not know about the human condition.
The narrative voice of the book affects a tone of clinical detachment, one in which drinking coffee and paranoid-type schizophrenia can be discussed with the same flat tone. Under the pretense of dispassion this voice embodies a whole raft of terrifying preconceptions. Just like the neurological disorders that appear at the start of the book, mental illnesses appear like lightning bolts, with all their aura of divine randomness. Even when etiologies are mentioned they’re invariably held to be either genetic or refer to other illnesses such as substance abuse disorders. At no point is there any sense that madness might be socially informed, that the forms it takes might be a reflection of the influences and pressures of the world that surrounds us.
On the ground, mental health professionals are often required to decide if someone’s thinking indicates a disturbance in their understanding of the world, and this is where the new DSM-5 definition of a delusion may usher in a quiet revolution in psychiatry. No longer are psychiatrists asked to decide whether the patient has “a false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary”. A wordy and unhelpful definition that has so many logical holes you could drive a herd of unicorns through it.
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Although the manual is American, it is much used elsewhere, despite the fact that the International Classification of Diseases, drawn up under the auspices of the World Health Organisation in Geneva, is usually seen as the official manual, if there is one. DSM-5 gives ICD codes when they match, and there is a project aimed at harmonising the two rulebooks. For an American, however, being assigned a DSM code determines whether your health insurance will pay for treatment, and what kind of treatment you get. (The DSM itself carries no recommendations for treatment.) A diagnosis may also have other more subtle effects on how patients think of themselves, how they feel and how they behave. Especially since nowadays, when told their diagnosis, patients tend to look it up online. There they obtain a sort of stereotype of how they ought to be feeling and behaving. Typing Acute Stress Disorder into Google will give you about 400,000 results.
Although his suggestion that mental illness is a myth is overly polemical Thomas Szasz offered a more nuanced critique, one that exposed the subtle relationship between social norms, small “p” politics, and psychiatric knowledge. Some of the concerns raised by Szasz and other “anti-psychiatrists” can be discerned in recent debate, prompted by the publication of DSM-5, about whether or not mental illness is “really real”.
(Find the image above here.)