Monday, June 17, 2013

The "walking worried"

The American Psychiatric Association either just has, or is about to, publish a new edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM-5], which is what is used to determine insurance reimbursement for mental illness. The definitions have changed over time and now they change again. We tend to medicalize every behavior that is distressing. I watched a psychiatrist on C-SPAN last night explain that he has concluded that the inclination to define every aberration as illness excuses what is sometimes appropriately treated as simply evil. Mental illness is certainly real, but what is it? I found this article, "The Problem With Psychiatry, the 'DSM,' and the Way We Study Mental Illness," illuminating:
.... The resounding lesson of the history of mental illness is that psychiatric theories and diagnostic categories shape the symptoms of patients. “As doctors’ own ideas about what constitutes ‘real’ disease change from time to time,” writes the medical historian Edward Shorter, “the symptoms 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, promote diagnostic inflation, and encourage inappropriate medication use.” ... “Disruptive mood dysregulation disorder” will turn temper tantrums into a mental illness and encourage a broadened use of antipsychotic drugs; new language describing attention deficit disorder that expands the diagnostic focus to adults will prompt a dramatic rise in the prescription of stimulants 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. ....

...[T]he declarations of the APA don’t have the power to create legions of mentally ill people by fiat, but rather that the number of people who struggle with their own minds stays somewhat constant.

What changes, it seems, is that they get categorized differently depending on the cultural landscape of the moment. Those walking worried who would have accepted the ubiquitous label of “anxiety” in the 1970s would accept the label of depression 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 biological facts and more like a kind of language. Someone in need of communicating 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 Victorian-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 theories 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 guidance about the workings of their minds, they are uniquely susceptible to being influenced by the psychiatric certainties of the moment. ....

.... We love to broadcast new mental-health epidemics. The dramatic rise of bulimia in the United Kingdom neatly coincided with the media frenzy surrounding the rumors and subsequent revelation that Princess Di suffered from the condition. Similarly, an American form of anorexia hit Hong Kong in the mid-1990s just after a wave of local media coverage brought attention to the disorder.

.... As things stand, we have little defense against such enthusiasms. “We are always just one blockbuster movie and some weekend therapist’s workshops 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 bet that we won’t have to wait nearly that long. .... [more]
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