The operative assumption behind many of these revisions is that clinicians will use their best judgment when considering treatment. “Mental disorders are beyond most people’s everyday experiences,” insists David Kupfer, chair of the DSM-5 Task Force. “Clinical training is required in order to make a diagnosis using DSM.” They won’t really label you mentally ill due to cancer pain; they won’t try to solve your financial and marital anxieties by prescribing an atypical anti-psychotic. Stop worrying excessively about the DSM revisions.
In fact, however, it has become common for people to receive medication rather than concerted counsel from busy doctors and psychiatrists, and that is why loosening these criteria is so problematic. “Psychiatry wants to be just like the rest of medicine, and a lot of its practitioners have stopped listening to people,” says Joel Paris, chair of McGill University’s department of psychiatry and author of An Intelligent Clinician’s Guide to the DSM-5. “The problem lies not with this particular edition [of the DSM] but with the ideology behind it, which is that mental illness is neurobiological, and that psychosocial factors are not that important. This is the position that has taken over academic and clinical psychiatry over recent decades, and it has led to a serious overprescription of medications.”
Here, I think of a friend who went to see a psychiatrist during his divorce, and emerged from his first session with a diagnosis for “soft bipolar” disorder and an prescription for anti-psychotics. Love, loss, guilt, thwarted dreams, sudden shocks, mounting pressures, these are slings and arrows, not chronic disease.
Dr. Frances frequently points out that even modest changes in diagnostic criteria lead to outbreaks of mental illness because of the power and ingenuity of pharmaceutical marketing. The incidence rates of attention deficit disorder, he offers by way of example, have tripled in the United States since a small amendment was made for DSM-IV.
It is, he and others argue, naive to presume that pharmaceutical companies will not make a meal of the new semantics. Eli Lilly already has its antidepressant, Cymbalta, in clinical trials for “bereavement-related depression.” In posting information about the trial, principal clinical investigator John Shuster said: “We expect that Cymbalta treatment will be associated with substantial mean reductions in measures of grief and bereavement, with improvements in measures of pain, symptom burden, and functional status.”
Is the widow’s veil a symptom burden? Does regaining your functional status win out over “death’s solemn stillness?”
What is motivating the APA to resist all the criticism is complex. Some point to a hopeless enmeshment with the agendas of drug companies, a phenomenon that has been well documented by journalists and by psychiatrists themselves over the past several years There is also pressure from patient support groups, and “key opinion leaders,” which is a euphemism for industry-funded experts.
And there is, ultimately, this obsession with taxonomy, with making the psyche conform to medical measurements. “They want psychiatric diagnoses to have solidity, but the fact is that psychiatry has produced anything but that kind of solidity,” says Edward Shorter, an historian of psychiatry at the University of Toronto. Psychiatry remains subjective, conjectural, with one person’s “excessive worry” being another person’s habit of mind, or cultural bent – something that looks the same but proves adaptive rather than dysfunctional in a different cultural context. It will ever be thus, that the mind eludes the measurement.
Is anxiety disordered? Sometimes, and sometimes not. Sometimes the focus of one’s dread is irrational, but only because the dread is displaced. Psychiatrist Aaron Beck, inventor of cognitive-behavioural therapy, wrote about phobias as an act of displacement. A man loses his mother and develops, apparently randomly, an acute fear of flying. It is easier to avoid airplanes than to avoid death. Once, when I was deeply unsettled by certain personal affairs, I unconsciously ignored them and decided, instead, that we were all about to die from the avian flu.
How do you code for and quantify emotional responses that shape-shift?