Posts tagged ‘DSM’
Welcome to the future of reductionist psychiatry. You can now be diagnosed, labeled and treated without a doctor ever having to even look you in the eye or hear the stories that make you tick. Just click the boxes for your symptoms, fill out the questionnaire and the complexities of the human psyche can be unraveled as quickly as e-filing your taxes in the last hour of tax day. Never mind the subtle differences that define us or the experiences that got us here.
This is not some luddite rant about the technology takeover, though to some extent there is a worthwhile wariness in that discussion. I’m talking about the power of the DSM, which was never meant to be a stand-alone collection of boxes to check off in diagnosing, now essentially uploaded and online to be used in just that fashion.
From Australia’s The Age:
MENTALLY ill Australians are increasingly being diagnosed and treated online in virtual psychiatric clinics, without ever seeing a doctor.
Patients suffering from depression, anxiety and post-traumatic stress disorder are being assessed by computer and given ”e-prescriptions” for online counselling courses instead of medication or treatment sessions with a psychologist or psychiatrist…
With e-therapy, patients are clinically diagnosed after completing psychiatric reviews by answering online questions
“Assessed by computer”? It makes you wonder what we need all these psychiatrists for? Apparently all we really need are the DSM committee and a handful of tech guys to work out the interface and we’ll be well on our way to solving those pesky problems that keep cropping up and reminding us how hopelessly human we all are.
One positive point is that it presents a shift from medicine and toward some sort of counseling but I see that aspect of it as short lived. It seems likely to follow the trend of “real life” psychiatry and revert to drug based care, printing out its e-prescriptions for the latest in pharmaceuticals. Also, it makes you wonder — if these kinds of treatments are so effective, why do we need a computer to veer away from drugs? I can see computer based communication and the easy transfer of information as useful but only as a supplement to truly involved care from a living, breathing human – not a replacement. I question the quality of online counseling when compared to real counseling. Of course it’s limited to relatively minor difficulties like depression, anxiety and PTSD. They wouldn’t dare try to treat the as yet uncharted depths of serious mental illness — would they?
In Melbourne, David Austin, the co-director of the National eTherapy Centre’s Anxiety Online program, which is run from Swinburne University of Technology, said the service did not attempt to treat people with more serious conditions such as schizophrenia or bipolar disorder but there was scope for that in the future.
“Within five to 20 years we will have a proven e-therapy for most of the psychological conditions. Once you do that, you have 24-hours-a-day, seven-days-a-week low-cost access for everyone,” said Professor Austin.
Everyone. Oh good. At least they’re planning ahead. This is where the drugs are likely to come into play as most things perceived as serious mental illness are treated with drugs as a chemical problem in the brain not simply a coping, life handling or perception problem.
Patients log on anonymously to complete modules on cognitive behavioural therapy and breathing and relaxation techniques through videos, podcasts, online forums and interactive questionnaires.
Next month, courses will begin for people with eating disorders and gambling addiction.
I’m convinced computers can be of some benefit in a therapeutic setting whether it’s to impart information, the support found in many forums or supplemental counseling. The biggest problem, though isn’t in the counseling aspect of it but in the assessing. While the move to computer based diagnosis promises to extend mental health care to more people, we need to question the level of care and its potential to do more harm than good. We’re talking about diagnosing people online that we’ve never met. The internet has proven to be an unreliable way to get to know people. Something gets lost in translation between the keyboard at one end and the screen at the other. That’s why some people hide behind them, filtering and crafting their online persona and others with the best and most honest intentions just don’t come across as themselves. Many would argue that the computer isn’t even a good way to determine whether someone is dateable but somehow we think we can ascertain someone’s mental and emotional state and diagnose them which will have a huge and far reaching impact on the course of their lives.
We are all complex individuals to varying degrees. One can no more experience another’s state of mind through a computer’s screen than the fullness of a symphony through its crackling plastic speakers. I can’t imagine letting the care of someone’s mental well being hinge on that poor a translation.
A recent opinion piece by Allen Frances for the LA Times is plainly pointing out the dangers of the new DSM’s broad strokes and the potential to paint too many “normal” people as mentally ill. It’s notable enough that mainstream press is presenting any criticism at all about psychiatry in general and the DSM in particular but Allen Frances was one of their own and no silent partner or low level underling either. He was the chairman of the committee that created the DSM-IV.
Our panel tried hard to be conservative and careful but inadvertently contributed to three false “epidemics” — attention deficit disorder, autism and childhood bipolar disorder. Clearly, our net was cast too wide and captured many “patients” who might have been far better off never entering the mental health system.
The first draft of the next edition of the DSM, posted for comment with much fanfare last month, is filled with suggestions that would multiply our mistakes and extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal. This wholesale medical imperialization of normality could potentially create tens of millions of innocent bystanders who would be mislabeled as having a mental disorder. The pharmaceutical industry would have a field day — despite the lack of solid evidence of any effective treatments for these newly proposed diagnoses.
Where the DSM-versus-normality boundary is drawn also influences insurance coverage, eligibility for disability and services, and legal status — to say nothing of stigma and the individual’s sense of personal control and responsibility.
It’s interesting to see someone in psychiatry addressing the notion of false epidemics of mental disorder when a committee decision and ever changing public opinion are all that separate a “real” epidemic from a false one. That said, committee decisions and public opinion have proven quite powerful and if you look back, the release of each DSM has brought on a rash of newly mentally ill. If history proves a good indicator, there will be millions of people who are normal today and mentally ill in 2013 — all thanks to a book with the power to categorize and medicalize the human condition. How much sorrow is too much? How excited can you be about everyday things before you are manic? And now with the proposed introduction of psychotic risk syndrome, anyone who isn’t deemed mentally ill can be subject to the book’s reach simply out of fear that they may be in time.
What are some of the most egregious invasions of normality suggested for DSM-V? “Binge eating disorder” is defined as one eating binge per week for three months. (Full disclosure: I, along with more than 6% of the population, would qualify.) “Minor neurocognitive disorder” would capture many people with no more than the expected memory problems of aging. Grieving after the loss of a loved one could frequently be misread as “major depression.” “Mixed anxiety depression” is defined by commonplace symptoms difficult to distinguish from the emotional pains of everyday life.
The media seldom addresses views critical of psychiatry but for psychiatrists to come out against the new proposals in such a public way is truly indicative of what’s at stake with the new DSM. You can bet that if psychiatrists are picking sides on this, it carries huge implications worth looking at. It doesn’t take much to see the power inherent in handing over our culture’s ability to define “normal” to a small committee comprised exclusively of people with something to gain and Frances is not exaggerating when he calls it “wholesale medical imperialization.” How much control are we willing to hand over? How far are we willing to let anyone go in defining us? How widely cast will the net be before it captures you? This is not an issue of special interest only to those marked as seriously mentally ill. Every label of mental illness is serious and with an ever broadening range of perceived illness encroaching upon a shrinking concept of normal, you may not be off the hook. Frances’ article says that it may not be too late to save ‘normal’ but I question whether ‘normal’ is worth saving.
See also: Allen Frances’ Opening Pandora’s Box: The 19 Worst suggestions for DSM5 in Psychiatric Times.
I don’t know if this coverage, questioning bordering on critical, is an anomaly or the beginning of the backlash but I hope it continues. It’s an unfortunate fact that television shapes the way millions think. Getting people to question whether human behavior needs a diagnosis can’t be a bad thing and it’s good to see the mainstream media casting even a shadow of doubt on the whole charade as it usually turns a blind eye in the name of its sponsors in pharma. Maybe the medical model has finally jumped the shark with the DSM-V.
A draft of the DSM-V has been released and is open to public comment. That’s news to me. I have yet to review any of it first hand but thought I’d put this out there to for anyone with the time and interest to take a look at it. There are some big changes in the works. While it’s not without its flaws, some of the more ludicrous attempts at creating new disorders have actually not made it into the draft and other labels are being revised. I may not have a chance to check it out and weigh in today but I’m definitely concerned with the implications that psychosis risk syndrome might carry. Think of how quickly you can lose your rights over a label. Putting a label aside for risks of symptoms is going to get messy. All things considered it is just a draft and the final isn’t due until 2013 so there’s still plenty of time for the wind to blow this thing in any direction. If nothing else, it’s a glimpse into the process, showing it is very much based on opinion and deliberation not objective medical discovery.
Here is a quick overview from MedPage Today and a few thoughts on it from Philip Dawdy at Furious Seasons and a brief breakdown at Beyond Meds with links to articles of interest to people following particular issues.
USA Today reports that Raymond DiGiuseppe, a researcher and psychology professor in Queens, NY seems to think we haven’t gone far enough in our efforts to pathologize the human condition. DiGiuseppe asserts that anger should be included in the DSM-V, which by way of its very presence in the book would classify it as a disease. That is the function of the DSM — to identify thought patterns, emotions and behaviors as diseases thus putting them within the increasingly invasive scope of psychiatry.
“Clinical psychology really targets depression and anxiety and really leaves out many human experiences or emotions,” he says, noting that other emotions such as disgust, envy and jealousy are also ignored.
There is the problem. There is a very urgent push, led by the APA and backed by Big Pharma to do away with any distinction between disease and emotion. In light of the fact that they’ve never had to prove the presence of disease, nothing really keeps them from reclassifying emotion as disease–so they do. If we’ve gotten clinical depression and generalized anxiety in, why not go for disgust, envy and jealousy?
I’m not saying anger isn’t difficult for some people to manage or that choosing to have people guide them through that anger would not be a wise choice in many cases but that’s a far cry from calling it a disease. I’m calling into question the notion that there is a biological cause to that anger and a chemical cure for it. I’m calling into question any system which would pathologize all human emotion and the legal, social and economic implications that would go along with it.
Do we honestly think anger is a disease — that it’s a biological malfunction? Of course not. We know why we’re angry. We often have good reasons to be angry. From a bad day at work to oppressive political regimes and many things in between, we have good reasons to be angry. Anger is very human and a necessary component for redirection and change.
“It destroys interpersonal relationships. It impedes sexual functioning. It negatively effects marital relationships. It negatively affects goal attainment,” he says.
DiGiuseppe says research shows that angry people make less money, are less likely to be promoted, almost always have poor romantic relationships and are more likely to be in the criminal justice system.
I refuse to accept the idea that the threshold between emotion and disease is a social one. If you are to assert that something is a disease, you must show that it is a biological malfunction, not that it can impede your job performance or disrupt your marital bliss. It is an especially dangerous road we are walking down and in the face of involuntary participation in the psychiatric system it is a dangerous road many are being corralled down. Justified anger is a very important part of free thought. It is the fight in you — and the way things are going, it looks like you may need it soon.