Pyschiatry and the DSM

Paul Grobstein's picture

Biology in Society Senior Seminar

Bryn Mawr College, Fall 2010

Session 7

Psychiatry and the Diagnostic and Statistical Manual (DSM)

Kwarlizzie, Collette


Questions

  1. Is psychiatry a valid science?
  2. Is illness real or contrived?
  3. Is psychiatric illness real or contrived
  4. Is the new DSM edition, DSM-IV really needed?  How valid is it and past manuals?
  5. Are the “disorders” in these manuals actually disorders? 

  6. Are these disorders biases of society? 

  7. Does the society shape the DSM? Or is it the DSM that shapes society?
  8. Does mental illness transcend culture? Or is it culture specific?

Background



The DSM categorizes mental disorders in the United States/ It is used in a wide array of contexts by clinicians and researchers in many different settings (Hospitals, clinics, insurance companies, etc). Initially, the DSM was developed from collected statistical information. It has evolved through four revisions to provide a common language and standard criteria for the categorization of mental disorders. Recently, controversial revisions of the DSM have been proposed and are currently under review. 
http://www.psych.org/mainmenu/research/dsmiv.aspx




What will be included in the New DSM-V?


“The new DSM-V will include many new categories to capture the milder subthreshhold versions of the existing more severe official disorders.” 
http://pn.psychiatryonline.org/content/44/16/4.1



Potential Issues with the DSM-V



“The DSM-V is supported only by thin literatures and will not have extensive field trials to predict the extent of the false positive risks, especially in primary care settings.” 
http://www.psychiatrictimes.com/dsm-5/content/article/10168/1425378)



“The new DSM-V will include many new categories to capture the milder subthreshhold versions of the existing more severe official disorders.” 
-This may flood the world with new false positives" 
http://www.psychiatrictimes.com/dsm-5/content/article/10168/1425378)



“The field testing for DSM-5 will receive no support from the National Institute of Mental Health”
 (http://www.psychiatrictimes.com/dsm-5/content/article/10168/1425378)


”We have already had years of scientific review through our NIH funded conference series, secondary data analyses, and literature reviews by DSM-V work groups and study groups and their advisors.…..Altogether, we have had more than 500 of the world’s best and brightest clinicians and researchers working together to provide a solid scientific basis for the proposed changes to DSM” 
(http://pn.psychiatryonline.org/content/44/16.4.1)
-Response from the American Psychiatric Association


Americanization of Mental Illness New York Times Magazine, 10 January 2010

Summary of in class discussion (hope)

In class on Monday Naa and Collette led a discussion of the DSM and its pros and cons.  We started out broadly with the question "is psychiatry a valid science?" This led to emphasizing the distinction between psychiatry and psychology. We then discussed whether the DSM should be the definitive manual for diagnosing psychiatric disorders? Moira made the comment that for those who fit into the specific categories in the DSM it can be helpful for understanding the problem and getting help.  The class agreed that people are often uncomfortable not being in a category, or having symptoms that are not neatly defined.

We also discussed the possibility of a new edition, edition 5, of the DSM being produced and the possibility that the DSM 5 might have broader categories leading to more diagnoses of mental illness. We discussed the pros and cons of this. On the pro side, we mentioned that more diagnoses could help reduce the stigma of mental illness and the possibility that many people with mental illness might be currently undiagnosed.

We also discussed the relationship between the DSM and society and how they shape each other.  We sited examples of disorders that are found in some cultures and not in others, such as the lack of dyslexia in Ghana and the lack of ADD in most other countries. This prompted the questions do societies create disorders, and if disorders are specific to societies can they be called disorders. We mentioned that the definition of disorders change, for example homosexuality used to be a disorder. Professor Grobstein stated that schizophrenia is not a disorder but a different way of viewing the world. Naa gave us the example of the choreographer of Cats, who might have had what some people would consider ADD but these characteristics made her quite successful. We then discussed what they role of psychiatry should be given that many disorders are culture dependent and what the role of the DSM should be in psychiatry.

Continued conversation and implications (Kwarlizzie, 25 October 2010)

It would be worth further exploring the history of the DSM in this regard.  My guess is that, originally, the DSM was conceived as an effort to reduce the tendency to judge potential mental health problems by norm socio-cultural standards, and has after the fact become itself a socio-cultural standard? - Paul Grobstein

This made me think of a article I read awhile ago that is similar to the Scientific American article I linked. The article claims that depression gives individuals an evolutionary advantage of being able to analyze problems better than non-depressed people. Understanding depression from this perspective make you think of depression less as a disorder and more as an adaptive function.  I think many other mental disorders can provide an evolutionary advantage based on the specific skills and talents they create. Maybe mental disorders are too much of a good thing. - lbonell

I think the question of whether or not mental illness derives from a culture or a culture ‘creates’ a mental illness is very interesting…What mental and physical health consequences come with this (relatively new) high-stress lifestyle that most Americans lead today? Researchers have noticed an increase in the diagnosis of ADD/ADHD in America in the past ten years. Are American’s daily demands too much for our mental health? Is it true that more American children today do not have the ‘healthy’ attention span that requires them to sit through a full day of school? Or is it not the child’s fault, but instead the structure of the classroom, and then later the structure of the workplace that inhibits them from holding their attention? In addition, I am not familiar with the instance of ADD/ADHD in other cultures around the world, but it would be intriguing to look into whether or not they have also seen an increasing trend in demands of the workplace and diagnoses of ADD/ADHD, or other mental illnesses. – mlhodges

On the other hand, I can't help but feel that the many disorders that are diagnosed on a spectrum today have created a very different society, and not necessarily in a positive light. Mental illnesses such as autism and ADHD are two examples of this. Should every child taking medication for ADHD actually be taking those meds? probably not. Should children who are kind of strange/quiet/shy/slower than their peers be definitively diagnosed as having autism? maybe not. I raised the point in class that the issue of autism has had a sincere effect/will continue to have a sincere effect on vaccination rates. Because of this, i think it is really important to actually narrow down what autism is (which may be impossible right now), so that when scientists are investigating a link between vaccines and autism, they are looking at cases of true autism as opposed to cases where a child is arbitrarily given the label. A diagnosis of autism is often arrived at as a result of ruling out all other options. So with this example in mind, I am not sure i can support extending diseases to more of a spectrum. - adowton

Conclusions to date:

  •  Definitions of mental illness may be more plastic than we previously thought: illness are different across cultures.
  • Mental illnesses also change with time and society.
  • Some behaviors that are acceptable today were not acceptable in the past
  • Some mental illnesses that exist today did not exist in past times
  • Mental illnesses could be so plastic because of the way societies change. As they change, new challenges rise, and these challenges can give rise to new forms of mental illnesses.
  • The DSM is a useful manual to have, but it is not without its problems
  • Among other things it is useful for the standardization of the treatment of mental disorders
  • The DSM is problematic because it categorizes mental disorders neatly, which is often not the case in reality.

Continuing discussion on on-line forum below

 

Comments

dfishervan's picture

The DSM and Society

Throughout class, we mentioned the idea that certain things detailed in the DSM are constructs of society. I do see the validity of this argument. It is unlikely that one will find video game addiction in a developing third world country’s version of the DSM where these technologies are not as prevalent and accessible. However, in the United States, there are people who suffer from a video game addiction which has harmful and debilitating consequences. Like any other addiction listed in the DSM, a person suffering from this technology-related addiction deserves medical treatment. While I agree with the validity of this argument, I think that it might actually contribute to the stigmatization of mental illness. By arguing that certain illnesses in the DSM are social constructs, we are detracting from the fact that certain mental illnesses are organic. We paint a person with a mental illness as a victim of society rather than certain uncontrollable biological causes. I fear that emphasizing society’s influence on the DSM may reinforce this misconception that people with mental illnesses suffer from a made up disease and are thus weaker than the rest of society.

 

smaley's picture

One thing that kind of

One thing that kind of bothers me about DSM 5, and the DSM in general, is how much private funding it seems to get, and how heavily it is relied upon by psychiatrists and insurance companies.  While I think that there do need to be guidelines that list the symptoms of each disorder, among other things, I feel that heavy reliance on such a book, can be a dangerous thing, especially if it prevents doctors from treating each of their patients as individuals.  With doctors constantly labeling everyone who comes through their door, based on the guidelines from the DSM, this could encourage stigmatization.  I feel like such a book is useful as a loose guideline, but as a strict set of rules it could cause more harm than good.  In fact, the only ones who would truly benefit from such a strict rule book would be the insurance companies.

Riki's picture

where is my mind?

I like what Moira was getting at in her post. I don't know if I would say that certain mental disorders are caused by our society, but I would certainly say that many are exacerbated by it. Now, if you are a high school student who wants to get into a good college, you need to be involved in several extra-curricular activities, you need to have good grades, you need to volunteer, you need to play an instrument, you need to have good SAT scores, you need to take AP classes, et cetera. That is maybe exaggerated but I think that these increased demands on students are leading to a lot of stress early on.

When I was a kid, we still played outside and knew how to entertain ourselves. Now everyone has cell phones and ipods and games and other small devices. Of course more kids are going to be diagnosed with ADD/ADHD now. I'm sure more adults will be too. I can't even sit down to have dinner with friends without them checking their phones and texting throughout the meal. We have quickly been trained to constantly be thinking about something else and never be totally focused on the present. So I would argue that nearly everyone in our technologically advanced society has ADD. Does the DSM address the role technology plays in ADD? I doubt it.

mlhodges's picture

 This is excellent. Facebook

 This is excellent. Facebook addiction should be in the DSM, too. 

hope's picture

It does seem like one of the

It does seem like one of the main functions of psychiatry and psychology is to make people more functional members of society, but i don't think that this is necessarily done with sinister, mind-controlling intentions.  Some people probably want to be able to fit into society better.  Using the example of homosexuality: when it was less acceptable to be gay there where some people who appreciated psychiatry trying to make them strait.  I'm not saying this is good, I just mean that when people in the future look back at what we consider a disorder i'm sure some things will shock them. In a sociology class I learned that most new behaviors start as sins, then become diseases, then become accepted, and this makes sense to be in terms of a lot of mental health issues.
Also, i had a wierd thought the other night.  If we really think that some mental health disorders such as  schizophrenia
or depression are not actually disorders but adaptive mechanisms, and people with these "disorders" can take medication to be like everybody else, should people without them be able to take drugs that make them more like schizophrenics?

Paul Grobstein's picture

mental health, culture, and the DSM

Lots of interesting issues on the table in class session and below, and useful intersections with our earlier session on Mental illness and stigmatization.  See my forum comment there for some relevant materials on Serendip. 

Among the issues from this session that I might to mull further is the notion that the goal of mental health is "to make people functioning members of society" (and a possible parallel goal for education, potentially relevant to our earlier discussion of The science of science education).  The problem here, of course, is that a goal of this sort risks making care-giving (and teaching) a maintainer of the socio-cultural status quo, something that shapes individuals in terms of cultural values while ignoring the possibility that socio-cultural values may themselves require adjustment.  Its a problem that received a lot of attention in the sixties but has, it seems to me, been relatively neglected since. 

It would be worth further exploring the history of the DSM in this regard.  My guess is that, originally, the DSM was conceived as an effort to reduce the tendency to judge potential mental health problems by norm socio-cultural standards, and has after the fact become itself a socio-cultural standard?

I want to mull further too the notion that "we all have mental disorders" (in parallel to the Danes all appearing with Stars of David during the second world war).  My guess is that this would not only help with the stigmatization problem but also open up some useful new ways of thinking about and doing research on mental health issues. 

lbonnell's picture

Disorders

In class we talked about how mental disorders can give individuals certain skills and talents. This made me think of a article I read awhile ago that is similar to the Scientific American article I linked. The article claims that depression gives individuals an evolutionary advantage of being able to analyze problems better than non-depressed people. Understanding depression from this perspective make you think of depression less as a disorder and more as an adaptive function.  I think many other mental disorders can provide an evolutionary advantage based on the specific skills and talents they create. Maybe mental disorders are too much of a good thing. 

http://www.scientificamerican.com/article.cfm?id=depressions-evolutionary 

 

Paul Grobstein's picture

mental "disorders": their adaptive sides?

For more along these lines,  see Thinking more about depression as "adaptive."  And I very much share your thought that it might make sense to focus at least as much on what mental "disorders" make possible as what they make more difficult. 

mlhodges's picture

I think the question of


I think the question of whether or not mental illness derives from a culture or a culture ‘creates’ a mental illness is very interesting. According to a show I recently saw on MSNBC, one in three American workers are chronically overworked, due to longer hours and the more demanding jobs in today’s market. In addition, people feel an increased pressure to overwork because of the fear that they will lose their job in this poor economy. What mental and physical health consequences come with this (relatively new) high-stress lifestyle that most Americans lead today? Researchers have noticed an increase in the diagnosis of ADD/ADHD in America in the past ten years. Are American’s daily demands too much for our mental health? Is it true that more American children today do not have the ‘healthy’ attention span that requires them to sit through a full day of school? Or is it not the child’s fault, but instead the structure of the classroom, and then later the structure of the workplace that inhibits them from holding their attention? It is interesting to look into the correlation between more ADD/ADHD diagnoses in America together with the increased demands placed on us.

In addition, I am not familiar with the instance of ADD/ADHD in other cultures around the world, but it would be intriguing to look into whether or not they have also seen an increasing trend in demands of the workplace and diagnoses of ADD/ADHD, or other mental illnesses. 

 

adowton's picture

An issue from class that i

An issue from class that i have been pondering about is whether or not broadening the diagnosis of many mental disorders into more of a spectrum would be a good thing. Like Hope said in her summary, one pro of this would potentially be the reduction of mental illness stigmatization. If mostly everyone fits somewhere on a much broader spectrum, the distinction between mentally fit and mentally ill may be reduced. On the other hand, I can't help but feel that the many disorders that are diagnosed on a spectrum today have created a very different society, and not necessarily in a positive light. Mental illnesses such as autism and ADHD are two examples of this. Should every child taking medication for ADHD actually be taking those meds? probably not. Should children who are kind of strange/quiet/shy/slower than their peers be definitively diagnosed as having autism? maybe not. I raised the point in class that the issue of autism has had a sincere effect/will continue to have a sincere effect on vaccination rates. Because of this, i think it is really important to actually narrow down what autism is (which may be impossible right now), so that when scientists are investigating a link between vaccines and autism, they are looking at cases of true autism as opposed to cases where a child is arbitrarily given the label. A diagnosis of autism is often arrived at as a result of ruling out all other options. So with this example in mind, I am not sure i can support extending diseases to more of a spectrum.

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