No mental illness has, or ever will be, diagnosed on the basis of medical signs, for a simple reason. If people who have been diagnosed with schizophrenia are found to have a brain lesion, they are suffering from a brain illness, not a mental illness. The presence of a medical sign in people who have been labelled mentally ill proves that they are not suffering from a mental illness. Psychiatry is, therefore, that branch of medicine where diagnoses of ‘illnesses’ are made in the absence of objective evidence: they are based, not on what people have, but on what they do and say. And if they act in ways that annoy, upset or offend others, they may find themselves diagnosed as mentally ill and treated medically against their will.
We are already in the midst of a false epidemic of ADD. Rates in kids that were 3-5% when DSM IV was published in 1994 have now jumped to 10%. In part this came from changes in DSM IV, but most of the inflation was caused by a marketing blitz to practitioners that accompanied new on-patent drugs amplified by new regulations that also allowed direct to consumer advertising to parents and teachers. In a sensible world, DSM 5 would now offer much tighter criteria for ADD and much clearer advice on the steps needed in its differential diagnosis. This would push back ,however feebly, against the skilled and well financed drug company sell. DSM 5 should work hard to improve its text, not play carelessly with the ADD criteria in a way that may unleash a whole set of dreadful unintended consequences- unneeded medication, stigma, lowered expectations, misallocation of resources, and contribution to the illegal secondary market peddling stimulants for recreation or performance enhancement.
The DSM 5 child and adolescent work group has perversely gone just the other way. It proposes to make an already far too easy diagnosis much looser.
For any mental illness or passing mood swing that may trouble a person, the Diagnostic and Statistical Manual of Mental Disorders — better known as the DSM — has a label and a code. Recurring bad dreams? That may be a Nightmare Disorder, or 307.47. Narcolepsy uses the same digits in a different order: 347.00. Fancy feather ticklers? That sounds like Fetishism, or 302.81. Then there’s the ultimate catch-all for vague sadness or uneasiness, General Anxiety Disorder, or 300.02. That’s a label almost everyone can lay claim to.Drug companies are particularly eager to win over faculty psychiatrists at prestigious academic medical centers. Called “key opinion leaders” (KOLs) by the industry, these are the people who through their writing and teaching influence how mental illness will be diagnosed and treated. They also publish much of the clinical research on drugs and, most importantly, largely determine the content of the DSM. In a sense, they are the best sales force the industry could have, and are worth every cent spent on them. Of the 170 contributors to the current version of the DSM (the DSM-IV-TR), almost all of whom would be described as KOLs, ninety-five had financial ties to drug companies, including all of the contributors to the sections on mood disorders and schizophrenia.
Do you have a shopping addiction disorder? Perhaps an addiction to food? Maybe one of your kids has Internet addiction disorder, or video-game attachment syndrome. Well, not quite yet, because these kinds of new mental diagnoses are only proposed, not final, for the new revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the bible of the American Psychiatric Association (APA).
And there is a terrible problem with this. The DSM was first created in the 1920s. Based on psychoanalytic theory, it enumerated fewer than 100 mental problems that a psychiatrist could diagnose, all of them attributable to environmental conditions, generally the role of parenting. We know now that this theoretical stance was limited and, in many cases, wrong. In 1980, the second revision of the DSM took place. Freud was discarded, and the revised bible now included several hundred disorders, all delineated by a list of observable symptoms and a framework for limiting and differentiating diagnoses.
Three versions later, the current DSM lists more than 1,000 disorders. No theories are espoused for their origins, though implicit in it is that there is a mix of genetic and environmental causes that shape neurological development. During this period of about three decades, the incidence of attention disorders in the general population has increased from 2 percent to 10 percent. In the 1980s, people diagnosed with bipolar disorder represented less than 1 percent of the population; now the number has increased to 5 percent. New diagnoses, like oppositional defiant disorder and conduct disorder, now cover as many as 5 percent of children.
Autism, which afflicted a tiny percentage of the population in the 1990s, now accounts for 1 out of every 100 children. What is wrong with this picture? Do we have an epidemic on our hands? Something in the water we drink, or the air we breathe?
Not only did the DSM become the bible of psychiatry, but like the real Bible, it depended a lot on something akin to revelation. There are no citations of scientific studies to support its decisions. That is an astonishing omission, because in all medical publications, whether journal articles or textbooks, statements of fact are supposed to be supported by citations of published scientific studies. (There are four separate “sourcebooks” for the current edition of the DSM that present the rationale for some decisions, along with references, but that is not the same thing as specific references.) It may be of much interest for a group of experts to get together and offer their opinions, but unless these opinions can be buttressed by evidence, they do not warrant the extraordinary deference shown to the DSM. The DSM-III was supplanted by the DSM-III-R in 1987, the DSM-IV in 1994, and the current version, the DSM-IV-TR (text revised) in 2000, which contains 365 diagnoses. “With each subsequent edition,” writes Daniel Carlat in his absorbing book, “the number of diagnostic categories multiplied, and the books became larger and more expensive. Each became a best seller for the APA, and DSM is now one of the major sources of income for the organization.” The DSM-IV sold over a million copies.