Today must be psych day on the blog. There’s a noteworthy column in Psychiatric Times, “Normality Is an Endangered Species: Psychiatric Fads and Overdiagnosis,” by Allen Frances, MD. He was chair of the task force that worked on the Diagnostic & Statistical Manual – DSM-IV – one edition of the “bible of psychiatry.” He is professor emeritus of psychiatry at Duke University School of Medicine. There’s a lot of common ground between what Dr. Frances writes and what Dr. Daniel Carlat (subject of my earlier blog posting today) writes about. Dr. Frances is concerned about the directions that might be taken in the authoring of DSM-V – now underway.
“Fads in psychiatric diagnosis come and go and have been with us as long as there has been psychiatry. The fads meet a deeply felt need to explain, or at least to label, what would otherwise be unexplainable human suffering and deviance. In recent years the pace has picked up and false “epidemics” have come in bunches involving an ever-increasing proportion of the population. We are now in the midst of at least 3 such epidemics–of autism, attention deficit, and childhood bipolar disorder. And unless it comes to its senses, DSM5 threatens to provoke several more (hypersexuality, binge eating, mixed anxiety depression, minor neurocognitive, and others).
Fads punctuate what has become a basic background of overdiagnosis. Normality is an endangered species. The National Institute of Mental Health estimates that, in any given year, 25 percent of the population (that’s almost 60 million people) has a diagnosable mental disorder. A prospective study found that, by age thirty-two, 50 percent of the general population had qualified for an anxiety disorder, 40 percent for depression, and 30 percent for alcohol abuse or dependence. Imagine what the rates will be like by the time these people hit fifty, or sixty-five, or eighty. In this brave new world of psychiatric overdiagnosis, will anyone get through life without a mental disorder?
The “epidemics” in psychiatry are caused by changing diagnostic fashions–the people don’t change, the labels do. There are no objective tests in psychiatry–no X-ray, laboratory, or exam that says definitively that someone does or does not have a mental disorder. What is diagnosed as mental disorder is very sensitive to professional and social contextual forces. Rates of disorder rise easily because mental disorder has such fluid boundaries with normality.
The media feeds off and feeds the public interest in mental disorders. This happens in two ways. Periodically, the media becomes obsessed with one or another celebrity whose public meltdown seems related to a real or imagined mental disorder. The mental disorder is then endlessly commented on and dissected by the media. The latest example is the Tiger Woods media frenzy which will likely lead to an “epidemic” of “sexual addiction.”
There is no objective way to determine what should be the proper rate of mental disorder in the general population. My view is that DSM-IV is almost certainly overinclusive, but I would not recommend tightening the criteria until we have clear evidence this would do more good than harm. The DSM-5 bias to thrust open the diagnostic floodgates is supported only by flimsy evidence that does not come close to warranting its great risks of harmful unintended consequences. It is too bad that there is no advocacy group for normality that could effectively push back against all the forces aligned to expand the reach of mental disorders.”