Are You Nuts?

The new DSM (Diagnostic and Statistical Manual of Mental Disorders), Fifth Edition (DSM V), is in the final stages of preparation for publication. The DSM is often referred to as the "psychiatrist's bible," which makes sense since psychiatrists rarely consult real Bibles, and "evil" is not a mental disorder to be dealt with. You can't make money by billing Medicare and the insurance companies for treating evil people, only "sick" ones.

One of the best ways to insure that your billing gets paid is to create all new mental disorders, or find arcane ways to define common character flaws as diseases to be treated. Psychiatrists, with the willing assistance of governmental bureaucrats and the public in general, have made a major industry out of mental illness. They alone get to decide what's "normal," and who are you to dispute them? Are you a psychiatrist?

Be sure to note that the operative word is "psychiatrist." Psychologists are another thing entirely. They don't have a big enough union to set national standards. Psychiatrists don't just get paid for talking and listening, and accomplishing nothing. Unlike psychologists, psychiatrists have medical degrees, which allows them to use drugs as part of the talk and listen. And unlike the average psychologist, psychiatrists have actually made some great breakthroughs in treating certain mental diseases with largely organic causes. Schizophrenia comes immediately to mind.

For psychiatrists, asking "And how do you feel about your five year old son acting out?" is not enough. He must follow up with "And how do you feel about my diagnosing Attention Deficit Hyperactivity Disorder and prescribing drugs to 'cure' him?" This was one of the earliest newly-created disorders which took boisterous boys and turned them into mental defectives in need of drugging. Your son's inattentive? He's rambunctious? He doesn't follow orders well? DSM comes to the rescue. Drug the little psycho until he's compliant. Christina Hoff Sommers did a pretty good job of describing how the radical feminists convinced psychiatrists to decide that little boys who don't act like little girls must be mentally ill and in need of drugs in The War Against Boys. Boys who didn't fit the proper mold were being brought into line with drugs as far back as the early 70s. Prior to that, we all just waited for them to grow up and behave. An occasional paddle had also been applied back in the Dark Ages.

The latest "advance" in psychiatry is the proposed addition to the DSM of "psychosis risk syndrome." Some teenagers and young adults do, indeed, show early signs of mental illness, occasionally including mild delusional behavior. We used to call those "phases," and though potentially serious, conscientious parents and friends simply helped wherever possible and waited to see if something actually came of it. By their own admission in the Journal of Clinical Psychiatry in a major study entitled Intervention in Individuals at Ultra-High Risk for Psychosis, the study found that seventy percent of those identified as potential risks never went on to develop the mental illness feared.

In The Wall Street Journal of February 19th, psychiatrist Sally Satel has said that: "Since we don't know who those [30%] will be, otherwise healthy kids will be exposed to potent antipsychotic medications and their side effects, such as diabetes and weight-gain." She goes on to conclude that treatment is not especially effective in forestalling psychotic illness in that minority destined to develop it, and therefore "until the science of prevention becomes more advanced, it is better to keep psychotic risk syndrome out of the main DSM, placing it in an Appendix for Further Research."

Another problem with modifications, additions to and deletions from the DSM is the problem of ever-shifting parameters which are often as sociological as they are medical. Is homosexuality a mental disorder? At one time, the DSM said "yes." Then it said "maybe." Now it says, "probably not." What does any of that have to do with medical treatment? Psychologists, politicians, moralists and theologians can argue over the issue from now until doomsday, but until somebody actually finds that elusive "gay gene," it is not a proper subject for a psychological-medical approach, let alone designation as "abnormal" or "normal." You can't "cure" or palliate a "disease" that has no scientifically-proven organic basis with drugs. So the psychiatrists should simply keep it out of the DSM, however it is described, and leave it to the rest of us to debate simply whether it's "right" or "wrong."

An example of changing the parameters of the ever-increasing diagnosis of autism is another example. That does not necessarily mean that autism itself is any more of a danger than it was 100 years ago, but as the definitions shift, so do the number of positive diagnoses of the disease. There have at least been some serious scientific studies which indicate strongly that some forms of autism are almost purely organic/genetic in nature, and therefore possibly amenable to drugs. There have also been studies that show that drugs can be the very cause of autism. Autism exists, there is science built around it, and therefore belongs in the DSM in some form or another.

But now the new DSM proposes to replace Asberger's Disorder as a separate category, and toss it into the larger category of Autism Spectrum Disorder. Asberger's kids tend to be very bright, overactive, have early language delays followed by the development of perfectly normal or even advanced speech abilities, and they (via their parents, of course) object to being place into the general category of Autism which largely describes children with serious concentration, intelligence and language deficiencies.

And let's not forget the potential Christine Jorgensens of this world. The proposal on the table is to remove the classification of Gender Identity Disorder. That has stirred up a big brouhaha among those who wish to change their sex. The camps are divided into those who believe the disorder should be removed from the DSM because it implies they are mentally ill, and those who wish it to remain in order to have their sex-change procedures covered by insurance and government programs.

The DSM III was the break from the original approach of simply describing Freudian concepts of unconscious conflict and stunted sexual development and leaving it to the individual psychiatrist to determine if his or her patient suffered from it, and whether psycho-medical procedures would alleviate the problem. Published in 1980, The DSM III switched to describing mental illnesses based on symptoms. Add up enough symptoms, and you had the disorder. That had the advantage of allowing two or three separate psychiatrists to interview the same patient, and agree that the patient had a disorder based on the symptoms rather than acute observation by one psychiatrist acting alone. It established a necessary uniformity, but it tended to leave little to individual observation and divergent treatment.

The DSM III carefully warned psychiatrists to be wary of diagnosing a disorder and automatically turning it into a mental disease to be treated with drugs. Depression, a common symptom of humans world-wide, can have so many causes that it is dangerous to assume it is always organic and permanent or even amenable to drug treatment. It can range from a serious but temporary condition caused by a current crisis or tragedy to a lifelong clinical problem which may or may not be amenable to drug treatment. And the treatment is often as dangerous as the condition. Yet by the time of DSM IV, the warnings had essentially been removed, and clinical depression was diagnosed far too often because at the time of the interview, the patient exhibited all the classic symptoms.

As Dr. Satel concludes, "In the preface to DSM III they said 'this symptomatic approach to defining mental disease is only one still frame in the ongoing process of attempting to better understand mental disorders.'" She concludes that "thirty years later, despite undeniable progress in brain science, we are saying much the same thing." Defining mental illness solely by an accumulation of symptoms does both the art and the patient a disservice, which DSM V ought not to be perpetuating. There is a great deal more to a human being than his or her symptoms, and psychiatrists, of all people, should recognize that and use the DSM as a tool, not as a Bible.