Volume 10  Number 2  May 17, 2013
Second Opinions

DSM-5: Terminology and Certainty. More Thoughts on Medical Naming: II

There must in art, as in medicine and fashion, be new names.

Proust

After eating an entire bull, a mountain lion felt so good he started roaring. He kept it up until a hunter came along and shot him. The moral: When you're full of bull, keep your mouth shut.

Will Rogers

On Naming and Billing Codes

The "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5) is the latest in a long list of DSM's going back to 1952. Seeking diagnostic perfection, doctors and patients alike feel comfort in the thought that naming is knowing and knowing is curing. "We see this" rarely reduces anxiety. Yet, by attempting to give a name to every clinical presentation, especially types of behavior, physicians and particularly psychiatrists, have caused a constellation of unintended disasters. The growth of new and unreliable designations resemble a kind of unrestrained systematic orthodoxy creating millions of new patients, and contributing dangerously to exploding medical costs. The National Institutes of Mental Health reports that one in five Americans over 18 has a "mental disorder! According to the CDC about half of Americans will meet the criteria for a DSM-IV disorder sometime in their life, with first onset usually in childhood or adolescence!" Can you believe this?

It started auspiciously enough in 1937 when the World Health Organization (WHO) developed ICD codes (International Classification of Diseases) using this straight forward and highly productive concept to assist in tracking mortality rates and international health trends, upgrading the list each decade. Ultimately, the number of ICD codes exploded to 14,400 this year. After 1965 Medicare and the AMA along with insurers developed CPT (Current Procedural Terminology) diagnostic and procedure codes linked to ICD codes. To my mind this has turned out to be an unmitigated disaster which continues to help bankrupt a disastrous private health care system.*

Linking these codes to ICD led to la carte billing for all medical procedures and visits; no more complete dinners remained on the menu. Aggregated services, blue plate specials, only exist in countries with government plans or "socialized" medicine. The attempt of the APA (American Psychiatric Association) to describe every variation of behavior with a name is nothing more than a delusional certitude that every psychiatric patient carries an ICD-10 code or fits a description in their latest DSM bible.

Do not assume that I reject the idea of psychiatric diagnosis. One cannot avoid some taxonomic approach to "mental" patients unless you lurch into Dr Szasz's corner. In my opinion, if more than the 450 diagnoses already deified by DSM were reassessed, and combined, 80%-90% of them could be excised. This could well result in major advances in psychiatric care and significant reduction of our healthcare costs. The real question is, will it ever be done, and if so, who will do it, and how and when?

When Some Behaviors Become Mental Illness

As many feared, the reach of psychiatry has been widely extended. My last newsletter referred to the labeling of homosexuality as mental illness in 1974, replaced, under pressure by violent protesters with clever euphemisms, "Sexual Orientation Disturbance," then "Ego Dystonic Sexual Orientation." Homosexuality was not fully removed until 1987. "Compulsive Hoarding Disorder," is no longer a subset of obsessive-compulsive behavior; it now stands on its very own. "Premenstrual Dysphoric Disorder," a severe form of premenstrual syndrome is also alive and well. Is this condition, suffered by one out of eight women, a psychiatric disease? Then we have "Binge Eating Disorder." What was formerly regarded as an advanced form of gluttony is now a full blown diagnosis, one of many eating disorders. By itself it tags millions of people who overeat with a psychiatric label.

The New York Times reported that the group working on depression declared early on it wanted to eliminate the so-called bereavement exclusion," ...that grieving the loss of a loved one should not be considered a clinical disorder, though it shares some outward sign of depression." Up to now even protracted grief has always been considered a normal reaction to death of a loved one; now it's called a "Major Depression Disorder".

Dr. Allen Frances, formerly the chair of the DSM-IV Task Force and currently Professor Emeritus, is the former Chairman of the Psychiatry and Behavioral Science department at Duke University School of Medicine. He writes "Disruptive Mood Dysregulation Disorder: DSM-5 will turn temper tantrums into a mental disorder... We have no idea whatever how this untested new diagnosis will play out in real life practice settings, but my fear is that it will exacerbate,... the already excessive and inappropriate use of medication in young children." Dr. Frances points out that during the past twenty years child psychiatry has already caused "... a tripling of cases of Attention Deficit Disorder (ADD) a more than twenty-times increase in Autistic Disorder, and a forty-times increase in childhood Bipolar Disorder." Bipolar disorder, which is characterized by episodes of depression and mania, had previously been an adult problem; now the diagnosis is given to children as young as two along with powerful psychiatric drugs and tranquilizers. See his revealing article.

The proposed definition of autism, wrote Dr. Fred Volkmar of the Yale School of Medicine, who had quit the committee in protest, presented research suggesting that only 45 percent or more of people who currently had autism or related diagnoses would be included under the proposed revision. Autism groups reacted immediately, fearing that change in the diagnosis would deny services to children and families who need them. The definition was altered, though defining the condition and its subsets, such as Asperger's Syndrome, remains highly controversial.

Next comes attention deficit disorder (ADD) in children, characterized by inattention, fidgeting, the child often appearing more isolated. Sometimes, when becoming frustrated they make noise, touch other children, or cause distractions. Then, they may become behavior problems for teachers. It's important for parents to know that not all bad behavior is the result of ADD. Because the vast majority of kids may display no more than temporary bad behavior, overdiagnosis of ADD, puts millions of children at risk for getting dosed with amphetamines. Attention Deficit Hyperactivity Disorder (ADHD) in both adults and children is also in the news. Increasing evidence suggests many, if not most symptoms of ADHD bear increasing resemblance to sleep deficits, a condition afflicting up to 30% of American adults and high school students.

Diagnostic Inflation: Truth vs. Consequences

Mental illness is a terrible thing to have and a terrible thing to misdiagnose. There is no way we can prove objectively the presence of mental illness in the present state of knowledge. Usually there is no visible sign of physical damage or impairment. We cannot invoke the evidence of physical, laboratory, or imaging findings in what we have come to regard as "modern" medicine. Rather, we rely on relatively subjective observation and judgment of human behavior. The problem is to distinguish between the behavior we see as a sign of "mental disease" or a relatively "normal" response of the worried well. After all, we are all subject to circumstances, disappointments, if not the tragedies, woven in the tapestry of life itself.

Who is diagnosed as being mentally ill has profound and often enduring consequences as Dr. Frances so accurately describes it: "Who is considered well and who is sick; what treatment is offered; who pays for it; who gets disability benefits; who is eligible for mental health, school, vocational, and other services; who gets to be hired for a job, can adopt a child, or pilot a plane, or qualifies for life insurance; whether a murderer is a criminal or a mental patient; what should be the damages awarded in lawsuits; and much, much more." See this fine book review by Dwight Garner, Two Pleas for Sanity in Judging Saneness (Dr. Frances's "Saving Normal," and Gary Greenberg's "Book of Woe").

Harsh Words from the National Institute of Mental Health (NIMH)

Critics of DSM who have been opposed to it for decades for lack of scientific validity have recently been joined by none other than Dr. Thomas Insel, Director of the National Institute of Mental Health (NIMH), the Federal agency which finances mental health research! Dr. Insel stated "While DSM has been described as a 'Bible' for the field, it is, at best, a dictionary, creating a set of labels and defining each...The weakness is its lack of validity." The stir caused by his article posted in a Director's blog posted on April 29 and expanded in a recent interview for the New York Times, "indicates a fundamental rift between the NIMH and the APA, two groups who up till now had appeared to be joined at the hip..." quoted here. The article has generated a great deal of comment. So far, there's been nothing from the APA.

Palliative and Captious Final Words

Perhaps, it is unfair to hold the APA and its controlling psychiatric hierarchy solely responsible for the failings of DSM 5 and previous editions. Any classification scheme will energize Big Pharma for the excesses, exaggeration, and lies they propogate in advertising psychotropic drugs, especially SSRI's from Prozac to Lexapro, Paxil, Zoloft. (I have previously noted that the European Union prohibits direct drug advertising to the public. New Zealand and the U.S. are the only advanced industrial countries which permit this.) Back on subject, any day in this merry month of May, 2013 you will be able to buy DSM-5 at Amazon. Hardcover version is only $189.

*Later, DSM diagnostic codes were linked to ICD, a great convenience, enabling psychiatrists to enter the main game. The latest DSM-IV to ICD-9 code matrix, (it will soon be DSM-5 and ICD-10-CM) lists 450 psychiatric codes.

Martin F. Sturman, MD, FACP

Copyright 2012, Mathemedics, Inc.

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