psychiatry in trouble - the new dsm-v

8/14/2019 Psychiatry in trouble - The new DSM-V

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The new DSM-5

By the bookThe American Psychiatric Associations latest diagnostic

manual remains a flawed attempt to categorise mental illnessMay 18th 2013 | New York The Economist

A BOOK with the tite !"ia#nostic an$ %tatistica Man&a o' Menta "isor$ers( )i'thE$ition* $oes not so&n$ $estine$ to +e a +estseer( ,artic&ary at -1.. a ,o,/B&t "%M( as it is known 'or short( is amost certain to +ecome one/ ts,re$ecessor( "%M( which was ,&+ishe$ in 1..4( has so$ more than 1m co,ies/"%M( which wi #o on sae on May 22n$( is ikey to $o at east as we/

The reason is that the "%M series( which is ,&+ishe$ +y the American 5sychiatricAssociation 6A5A7( has +ecome the #o+a stan$ar$ 'or the $escri,tion o' mentainess/ n$ee$( the "%M is treate$ +y many ,eo,e ess as a me$ica han$+ookan$ more as hoy writ/ ns&rers &se it to $eci$e whether or not to coer aiments/An$ $ia#noses +ase$ on it $etermine whether ,eo,e #et s,ecia serices atschoo9 whether they :&ai'y 'or $isa+iity +ene'its9 whether they are sti#matise$in their careers9 een whether they are a+e to a$o,t chi$ren/ "octors( ,atients($r com,anies an$ ins&rers hae a th&s +een waitin# 'or the atest e$ition o'what has +ecome known as the ,sychiatric +i+e/

The "%M;s ,&r,ose is to set strict criteria 'or i$enti'yin# menta $isor$ers/ This iss&,,ose$ to make $ia#noses more reia+e< a a&$a+e aim/ To that en$( morethan 1(00 e=,erts hae s,ent oer a $eca$e a+o&rin#/ n $oin# so( thoh( theyhae s&ccee$e$ in a$$in# to( rather than s&+tractin# 'rom( criticism that the "%M

has +ecome a monster/ n the eyes o' many critics it is a ehice 'or mis$ia#nosis(oer$ia#nosis( the me$icaisation o' norma +ehaio&r an$ the ,rescri,tion o' aar#e n&m+er o' &nnecessary $rs/

Chapter and verseThe "%M( the 'irst ersion o' which was ,&+ishe$ in 1.2( has aways attracte$controersy/ That ersion( an$ the secon$ e$ition( ,&+ishe$ in 1.>8( reie$ on the,remise that menta iness was a ne&rotic res,onse to a ,atient;s e=,erience an$enironment/ 5eo,e with the same sym,toms co&$ there'ore receie wi$y$i''erent $ia#noses/ "i''erent inter,retations o' e=,erience an$ enironment asomeant that c&t&ra $i''erences a''ecte$ $ia#nosis/ n 1.?1 @o+ert Ken$e$emonstrate$ this +y showin# that( 'ace$ with the same ,atients( American,sychiatrists were m&ch more ikey to $ia#nose them as schio,hrenic than wereBritish ,sychiatrists/

The thir$ "%M( ,&+ishe$ in 1.80( intro$&ce$ a new a,,roachaso 'oowe$ inthe 'o&rth in 1..4/ "%M acknowe$#e$ that ,sychiatrists ha$ a ,oor&n$erstan$in# o' the ,hysioo#ica ca&se o' menta iness/ nstea$ s,eci'ic(o+sere$ sym,toms +ecame the $ia#nostic criteria( an$ c&sters o' them( knownme$icay as syn$romes( that a,,eare$ to coe=ist in in$ii$&a ,atients were#ien a+es/ The ho,e was that +ioo#ica markers o' s&ch syn$romes wo&$ +e$iscoere$ as ,hysioo#ica &n$erstan$in# increase$/

This was a reasona+e a,,roach in ,rinci,e/ n ,ractice( thoh( the ines $ii$in#$i''erent $isor$ers are +&rry/ The sym,toms &se$ to $e'ine them o'ten $o notc&ster neaty in the way that those o' tr&e syn$romes wo&$( an$ the statistica


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ei$ence 'or their e=istence is sometimes s,arse/ Nor( in most cases( hae theho,e$'or +ioo#ica markers t&rne$ &,an$ to the e=tent that they hae( theyhae m&$$ie$ the waters( rather than cari'yin# them/

The +i##est m&$$yin#s hae come 'rom +rain scannin# an$ #enetics/ Most,sychiatrists( een those sce,tica o' the "%M;s a,,roach( wo&$ acce,t the i$eathat thin#s ike a&tism( maCor $e,ression an$ schio,hrenia are $i''erent 'romeach other/

Doweer( a st&$y ,&+ishe$ this year +y a #ro&, cae$ the 5sychiatric enomicsFonsorti&m( which has ooke$ 'or inks +etween #enetic ariations an$ ,sychiatric$isor$ers in tens o' tho&san$s o' ,atients( has 'o&n$ that ariations in 'o&r ,aceswere common to ,eo,e $ia#nose$( &sin# the "%M;s criteria( with attention $e'icithy,eractiity $isor$er 6A"D"7( a&tism( +i,oar $isor$er( maCor $e,ression an$schio,hrenia/ Gikewise( a series o' ,a,ers oer the ,ast $eca$e hae shownsimiar a+norma actiation o' ,art o' the +rain cae$ the amy#$aa in ,eo,e$ia#nose$ with an=iety( maCor $e,ression an$ ,osttra&matic stress $isor$er/

%&ch res&ts s#est that the "%M;s a,,roach o' ,acin# ,atients in $ia#nostic

sios is :&estiona+e/ As "an Baer o' "&ke Hniersity( who sere$ on "%M;stask'orce( ,&ts it( !Ie;re +asicay $rawin# arti'icia ines( an$ the +o$y an$ themin$ $o not work ike that/*

The new "%M as,ires to inc&$e o+Cectie criteria in its man&a/ t aso seeks toscra, nonsensica( strict ines +etween certain $isor$ers/

t has! for e"ample! chun#ed together four previously separatediagnoses! including autism and Aspergers syndrome! into one disorderof varying severity! #nown as $autism spectrum disorder%& n this! it isfollowing clinical practice! for the idea of an autistic spectrum has 'eenaround for a long time& And the unfortunate truth is that it is still far too

early to use 'iological mar#ers as criteria for diagnosis&!The h&man +rainis the most im,ossi+y com,e= thin# in the &nierse(* says Aen )rances( who e$the $eeo,ment o' "%M/ !t $oes not yie$ its secrets easiy/*

Iorse( ar#&es "r )rances( "%M has not sto,,e$ the rise in the n&m+er o'ae#e$y reco#nisa+e an$ namea+e menta con$itions( many o' which anne=into ,sychiatry thin#s that the man in the street wo&$ think norma( i' not aways$esira+e( +ehaio&r/ Fhi$ren may now( 'or e=am,e( +e $ia#nose$ with!$isr&,tie moo$ $ysre#&ation $isor$er*what &se$ to +e known as tem,ertantr&ms/ 5ast ersions o' the "%M sti,&ate$ that those mo&rnin# a $eath sho&$not +e cassi'ie$ as $e,resse$/ "%M scra,s this !+ereaement e=c&sion*/ t aso

inc&$es a new +in#eeatin# $isor$er( $e'ine$ as eatin# to e=cess at east once aweek oer the ,reio&s three months/ %&ch a $ia#nosis coers miions o'Americans( ro,in# in ,eo,e who wo&$ not remotey consi$er that they werementay i/ "%M $oes not( a'ter some $e+ate amon# those who ,&t it to#ether(make a$$iction to internet #amin# a 'orma $isor$er/ B&t it recommen$s '&rtherresearch into the !con$ition*/

rie'/ n$ence/ Hnheathy ha+its/ A( it seems( may +e cassi'ie$ as menta$eran#ement( an$ treate$ as s&ch/ An$ the sets o' sym,toms $escri+e$ +y the"%M are o'ten common/ More than one American chi$ in ten has +een $ia#nose$(&sin# the "%M;s $e'inition( with A"D"an$ a+o&t twothir$s o' those so

$ia#nose$ are now ,rescri+e$ $rs/t is this oer$ia#nosis an$ oertreatment that is the chie' criticism o' the "%Mor( rather( o' the ,ower it wie$s in the ,ro'ession o' ,sychiatry/ That ,ower(howeer( may +e wanin#/


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(iterary criticism"%M cate#ories hae on# +een &se$ in research/ That is chan#in#/ Other areas o'me$icine( cancer in ,artic&ar( hae +een trans'orme$ +y +etter &n$erstan$in# o'the +ioo#ica $riers o' $isease/ America;s Nationa nstit&te o' Menta Death6NMD7 ho,es that wi trans'orm ,sychiatry( too/ The NMD seeks to &se #enetics(ima#in# an$ co#nitie science to create new $ia#nostic criteria/ Thomas nse( theNMD;s $irector( has s,eci'icay im,ore$ researchers not to +e con'ine$ +y "%M

;s strict r&es/ A+i$in# +y "%M cate#ories may ,reent scientists 'rom&n$erstan$in# the &n$eryin# ca&ses o' sickness/

%ti( o+Cectie a+oratory meas&res 'or menta iness are a on# way o''/ The A5Asays "%M wi +e contin&o&sy &,$ate$ to res,on$ to new $iscoeries/ )or now(howeer( ,atients; treatment wi +e #&i$e$ +y the im,er'ect man&a/ !The "%M is,&rey a ,ro$&ct o' the state o' o&r knowe$#e at this ,oint in time(* says Je''reyGie+erman( the chairman o' Fo&m+ia Hniersity;s ,sychiatry $e,artment an$,resi$enteect o' the A5A/ !The state o' o&r knowe$#e is not com,ete/*


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The DSM-5 Attention,everyoneMay 22n$ 2013(The Economist

A)TE@ neary two $eca$es( the new "%M has arrie$/ The "ia#nostic an$%tatistica Man&a o' Menta "isor$ers is a .4?,a#e #&i$e to aiments o' the min$/5&+ishe$ on May 22n$ +y the American 5sychiatric Association 6A5A7( it istss,eci'ic sym,toms to +e attri+&te$ to this $isor$er or that/ The "%M is heyin'&entia/ ts cate#ories #&i$e research an$ treatment 'or miions o' ,atients inAmerica an$ esewhere/ Fr&ciay( it aso ,ro,es the ,sychiatry in$&stryi' a$isor$er is inc&$e$ in the "%M( ins&rers are more ikey to ,ay 'or it/

Anythin# so im,ortant is ri,e 'or controersy/ This "%M( in ,artic&ar( has ins,ire$'its/ Fritics 6inc&$in#( to a $e#ree( this news,a,er7 yow that the "%M wi ea$ to

oer$ia#nosis that +ene'its ,sychiatrists an$ $r com,anies/ The "%M;s a&thorsco&nter that the #&i$e re'ects the '& e=tent o' c&rrent knowe$#e( which theya$mit is im,er'ect/ )&rthermore( the "%M is an essentia too to i$enti'y ,atients innee$ o' he,/

At the A5A;s ann&a meetin# in %an )rancisco on May 18th( the #ro&,;s ea$ers#athere$ re,orters in a s&+s&++asement to to&t e=citin# chan#es to the "%M/

The man&a has new toos to he, ,atients an$ ,sychiatrists with assessment(yo&r corres,on$ent an$ the others were to$/ Fha,ters are reor#anise$ to re'ectnew &n$erstan$in# in #enetics an$ ne&roima#in#/

B&t the more ,rominent $e+ate was at street ee( where the ,oar e=tremes o'

the 'i#ht were on $is,ay/ On one si$e o' the street were %cientoo#ists ho$in#si#ns with ario&s so#ans( inc&$in# !Fhi$hoo$ is not a menta $isor$er*/ On theother si$e were +&ses( there to take atten$ees to an$ 'rom the meetin#(em+aone$ with a$ertisements 'or enentech( a ,harmace&tica com,any/

Ihy is the controersy so im,ortant Eeen ,ercent o' American schooa#echi$ren hae +een $ia#nose$ with attention$e'icitLhy,eractiity $isor$er6A"D"7/ Astonishin#y( one in 'ie +oys a#e$ 141? hae +een th&s cassi'ie$/Amon# those c&rrenty a+ee$ as hain# A"D"( twothir$s are on ,rescri,tion$rs/

The "%M is ikey to ea$ to een more A"D" $ia#noses( ,artic&ary 'or teena#ers

an$ a$&ts/ The ,rior "%M( ,&+ishe$ in 1..4( re:&ire$ sym,toms to +e ,resent+e'ore the a#e o' seen/ The new ersion raises that to 12/ A$&ts no on#er haeto ,resent si= sym,toms to +e $ia#nose$/ The new thresho$ is 'ie/

This wi hae a +i# im,act on $r saes/ On May 21st E=,ress %cri,ts( a,harmacy+ene'it mana#er( ,&+ishe$ its ann&a re,ort on American $r tren$s/

The com,any e=,ects +roa$ $r s,en$in# 'or common aiments( s&ch as asthmaan$ hy,ertension( to 'a +y 4 oer the ne=t three years/ Doweer( saes o'attention$isor$er $rs wi C&m, +y 2 oer the same ,erio$/ The s,ike is $&enot to the arria o' e=,ensie new treatment( +&t to a s,ike in ,rescri,tionsamon# a$&ts/ The &se o' attention $rs is hi#hest in Americas so&th/

This &n$erscores somethin# most ,sychiatrists know we/ Neither a rise in $rsaes nor #eo#ra,hic ariation can +e e=,aine$ ,&rey +y ,reaence o' a menta$isor$er/ @ather( these shi'ts re'ect chan#es in $ia#nostic ,ractice/ %ome o' thenewy $ia#nose$ ,atients may hae +een &nC&sty ne#ecte$ to $ate/ Many wi +e
http://www.economist.com/news/science-and-technology/21578024-american-psychiatric-associations-latest-diagnostic-manual-remains-flawedhttp://www.economist.com/news/science-and-technology/21578024-american-psychiatric-associations-latest-diagnostic-manual-remains-flawedhttp://www.economist.com/news/leaders/21578050-single-book-has-come-dominate-psychiatry-dangerous-shrink-wrappinghttp://www.economist.com/news/leaders/21578050-single-book-has-come-dominate-psychiatry-dangerous-shrink-wrappinghttp://www.economist.com/news/science-and-technology/21578024-american-psychiatric-associations-latest-diagnostic-manual-remains-flawedhttp://www.economist.com/news/science-and-technology/21578024-american-psychiatric-associations-latest-diagnostic-manual-remains-flawed


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the res&t o' more rea=e$ $ia#nostic r&es/

This is ,ro+ematic( not east +eca&se the oertreatment o' some menta$isor$ers coinci$es with the &n$ertreatment o' others/ 5&+ic serices 'or thementay i $ecine$ $&rin# the recession/ nstea$ o' receiin# ,ro,er treatment(many en$ &, in ,rison/ More than ha' o' America;s ,rison ,o,&ation has somekin$ o' menta iness/


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PsychiatryA single 'oo# has come to dominate psychiatry& That isdangerousMay 18th 2013 | The Economist

TDE h&man +rain is the most com,e= o+Cect in the known &nierse/ t contains100 +iion nere ces/ Fonsi$erin# how com,e= that is( it #oes wron# remarka+yrarey/

B&t #o wron# it sometimes $oes/ Ihich is why( since 1.2( the American5sychiatric Association has ,&+ishe$ its !"ia#nostic an$ %tatistica Man&a o'Menta "isor$ers*( the "%M/ This +ook( the newest ersion o' which wi hit thesho,s on May 22n$ 6see artice7( contains the association;s thinkin# on whatconstit&tes a $isor$er o' the min$/ t is cons&te$ not ony +y ,sychiatrists( +&taso +y ins&rance 'irms( $r com,anies an$ an=io&s ,atients an$ ,arentsnotony in America( +&t aro&n$ the wor$/ t has +ecome the in$&stry stan$ar$ 'or$e'inin# what is an$ is not a menta iness( an$ th&s who #ets treate$( an$ who

,ays 'or treatment/

No other maCor +ranch o' me$icine has s&ch a sin#e te=t( with so m&ch ,oweroer ,eo,e;s ies/ An$ that is worryin#/ Beca&se in no other +ranch o' me$icineis the scienti'ic reaity &n$er,innin# the ,rono&ncements o' $octors so &ncertain/

The categorical imperative

This &ncertainty 'ows 'rom a ,ro'o&n$ i#norance a+o&t how +rains act&ay work/Ne&roscientists &n$erstan$ how nere ces work/ They aso know which +its o'the +rain $ea with ision( ocomotion( an#&a#e( memory an$ s&chike/ B&t+etween these two anatomica ees a is $arkness/ 5sychiatrists hae th&s ha$

to &se +ehaio&r ,atterns as ,ro=ies 'or &n$eryin# ,ro+ems/ An$ whatconstit&tes a ,attern is too o'ten a matter o' o,inion rather than a statisticayri#oro&s 'act/

t is this $esire to 'in$ an$ cassi'y ,atterns which #ies the "%M its ,ower/ Bynamin# thin#s it #ies sha,e to the 'e$#in# science/ That is not a +a$ thin# in,rinci,e/ B&t in ,ractice it has #one too 'ar/ The main criticisms are that itme$icaises norma +ehaio&r an$ that the strict cate#ories o' menta iness itcreates are increasin#y at o$$s with what research s#ests is act&ay #oin# onin the +rain/

Both criticisms are &timatey a+o&t names/ The "%M #ies names ike !$isr&,tie

moo$ $ysre#&ation $isor$er* to tem,er tantr&ms in chi$ren an$ !+in#e eatin#$isor$er* to those who ten$ to oereat/ ' these were mere a+es( ,erha,s itwo&$ not matter 6thoh in the area o' menta heath een a a+e can +e$amnin#7/ B&t $ia#nosis 're:&enty ea$s to ,rescri,tion( an$ ots o' ,is are th&s+ein# ,o,,e$ +y ,eo,e whose nee$ to take them is( to say the east(:&estiona+e/

The way the "%M cassi'ies those who &n:&estiona+y are i is aso &n$er attack/%chio,hrenia( maCor $e,ression an$ some 'orms o' a&tism are $isa+in#con$itions that hae on# +een consi$ere$ se,arate $iseases/ B&t mo$erntechni:&es o' #ene anaysis an$ +rain scannin# are ea$in# some researchers to

won$er whether they reay can +e $istin#&ishe$ in the way that( say( ario&s'orms o' e&kaemia can +e $i''erentiate$'or their +ioo#ica &n$er,innin#s seemto oera,/ Iitho&t a ,ro,er $ia#nosis( ,ro,er treatment is har$/

eneration o' the "%M is aso harm'& in research/ Thomas nse( the hea$ o'
http://www.economist.com/news/science-and-technology/21578024-american-psychiatric-associations-latest-diagnostic-manual-remains-flawedhttp://www.economist.com/news/science-and-technology/21578024-american-psychiatric-associations-latest-diagnostic-manual-remains-flawed


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America;s Nationa nstit&te o' Menta Death( has ,&+icy enco&ra#e$ scientistsnot to +e constraine$ +y its a,,roach( est it ,reent them 'in$in# $ia#noses an$treatments/ n terms o' $ia#nosis( a 'ew ,sychiatrists 6inc&$in# those whocon$&cte$ the #enetics an$ +rainscannin# st&$ies7 now ,&+icy ,oint to the"%M;s $e'iciencies9 yet the "%M;s $e'initions an$ certainties are too $ee,yin#raine$ 'or this criticism to hae hit home/ The '& conse:&ences o' that wi not+e o+io&s 'or a on# time/ B&t the c&rrent oerreiance on one ,oint o' iew in

this e=tremey &ncertain science is heathy neither 'or ,sychiatry( nor 'or those ittreats/

psychiatry in trouble - the new dsm-v

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