With drafts of the latest edition of the world’s leading psychiatry manual emerging, critics question the growing medicalisation of life’s problems
OVER THE past three decades, unhappiness has been redefined as depression, shyness has been reclassified as social anxiety disorder – even trivial complaints such as fussy eating are now being viewed through a psychiatric prism. Some of this is due to a single book, the Diagnostic and Statistical Manual, which critics claim is contributing to the ever-expanding empire of mental health. The next official edition of the DSM will be published in May 2013, but draft versions are currently doing the rounds.
Books abound on the creeping medicalisation of everyday life, television shows like In Treatmentand The Sopranosrevolve around endless therapy sessions, as do films by the likes of Woody Allen. According to clinical psychotherapist Áine Tubridy: "Many people's problems have sociological causes, not medical ones. They are problems of living. Society needs to recognise that for many people life is bloody hard," she says.
But there is growing criticism of the DSMitself and the entire model of diagnoses from within the psychiatric establishment.
Consultant psychiatrist Dr Pat Bracken, clinical director of mental health services in west Cork, is unrelenting in his criticism of over-reliance on the DSM.
"Despite being a primarily American book, the DSMis used universally. The alternative is the I nternational Classification of Diseasespublished by the World Health Organisation," he says.
"The DSMreally took off in the 1980s, introducing what are called 'operationalised definitions'. That seemed more scientific – a psychiatrist could say: 'This person fits these diagnostic criteria.' It introduced a new way of thinking and a focus on diagnosis."
The criticism boils down to this: reliance on the DSMreduces psychiatry to little more than a consensus on what kind of behaviour or thoughts are abnormal, not an evidence-based analysis of what is wrong in people's lives.
Bracken says along with the
DSM
’s rise there was a corresponding demise in the use of psychotherapy within the medical profession, even if there was an expansion of private use of therapies and counselling, many of which are of dubious efficacy. For Bracken though, the medicalisation of life’s problems creates the worry that “expert” intervention in private life is often disempowering and misses the point.
“The
DSM
reflects a growing trend to seek ‘experts’ for problems that once wouldn’t have been the domain of the expert: gambling, social anxiety, marriage problems and so on,” says Bracken. “These were once seen as the vicissitudes of life. The demise of organised religion has also contributed to the growing social demand. The
DSM
legitimises that process and contributes to it,” he says.
This argument links the medical critique of the DSMback to its social implications. The repercussions of privatised social lives driven by the breakup of traditional sources of solidarity outside the family unit – organised religion, trade unions, political parties and other communal organisations – has left individuals confused, lonely and often frightened and encouraged to seek therapy when in fact the problem is a socio-political one.
What, though, is to be done when a patient arrives at their GP’s surgery in despair?
Niall Crumlish, deputy external affairs and policy director of the College of Psychiatry of Ireland, is a locum consultant psychiatrist at St James’s Hospital in Dublin. While he recognises the limitations of psychiatric diagnosis, a patient who asks for help must be given it, he says.
“There are cases for arguing that we are both over-medicalised and under-medicalised,” he says. “There is a huge number of people presenting to primary care providers [seeking psychiatric help] but there are also many not presenting, people with major depression who are functioning but at a much lower level than they might.
"Without the DSMwe'd be losing a basic foundation for what we are doing. There is some validity to diagnosis. There is such a thing as a depressive syndrome that you could produce biologically if you were so minded," he says.
An article published in the Journal of the American Medical Associationthis July by two of the DSM's authors argued the forthcoming fifth edition should be of interest to all health providers, not just psychiatrists.
The DSMis in part a product of the US psychiatric establishment being rocked in the 1960s. David Rosenhan, a follower of the controversial Scottish "anti-psychiatrist" Dr RD Laing, virtually smashed psychoanalysis as it was practised in America almost single handedly.
Rosenhan and some colleagues presented themselves at several mental hospitals claiming to have a sole auditory hallucination – a voice in their heads saying “thud” – and then behaved normally. They were all diagnosed with a variety of mental illnesses: schizophrenia and manic-depressive psychosis. They were eventually released, months later, when they “admitted” they were mentally ill and pretended to get better, demonstrating – they said – that psychiatrists were unable to distinguish between the sane and the insane.
The experiment’s objective wasn’t to prove the obvious point that it is possible to pretend to be mentally ill. Instead it demonstrated that, once admitted, all behaviour by patients is pathologised and ordinary actions were taken as evidence of illness. This rocked the establishment and one hospital challenged Rosenhan to do it again. He agreed and the hospital soon declared it had discovered 41 fakes. Rosenhan then announced he had sent no one for the second experiment.
According to Bracken, this body blow coincided with the increasing use of drug treatment for illnesses: "In the 1950s and 1960s, psychoanalysis was very dominant. Then you had a rejection of that and a move toward the DSMand the psychopharmacology revolution. "Today, the efficacy of the drugs is being called into question," he says.
By moving away from endless psychoanalysis the diagnostic model favoured by the DSM, particularly from the 1980 third edition onwards, seemed to offer an answer to the problem. Patients symptoms were analysed on a more or less statistical basis and those who fit a specified pattern were declared to have the relevant condition.
Although it has since spread worldwide, the American bias of the DSMis clear: given that unhappiness is not covered by health insurance policies but major depression is, a massive expansion of diagnoses of depression and related illnesses is unsurprising. However, DSMcritics argue the book is part of a wider reshaping of our understanding of what it is to be human, not simply a licence to malinger but pathologising everyday experiences.
Its defenders respond that without it psychiatrists would find themselves almost powerless when faced with people’s very real problems.
Crumlish says the validity of the medical and social critiques of the DSMdoesn't detract from the fact that both GPs and psychiatrists are daily faced with patients in sever psychic distress and that the imperative must be to help them, not to simply discuss the meaning of unhappiness, however important that debate is for both the profession and wider society.
“What’s really important and difficult to do with the patient and his or her family is to tease out whether or not an event caused something or if it is a symptom of the syndrome,” he says.
“Psychiatry in general is aware that these diagnoses are not perfect but what’s wrong with helping people one at at time? We can’t all be transformative. Diagnoses are syndromal: their legitimacy comes from the fact that they’ve been observed thousands of times.”
Conversely, Pat Bracken argues for a sea-change in how doctors work to frame the problems brought to them by their patients.
“My own feeling is that we need a complete rethink. In a nutshell, my argument is that we’ve traditionally used a technical idiom to frame mental health problems, focusing on diagnosis, classification and medical interventions. In this idiom, the non-technical aspects of mental health are understood as secondary. However, empirical research, as well as the testimony of service-users, points to the primacy of relationships, meanings and values in the field of mental health. We need a revolution that would put these non-technical issues at the centre ground.
“Sometimes it’s important – for organic conditions like dementia, for instance – but for most of my work I feel I don’t have to provide a [formal] diagnosis. What patients respond to is honesty. Mental health work is different to the rest of medicine. We face problems with people’s thoughts, feelings and behaviours and these cannot always be grasped in a medical vocabulary of diagnosis, pathology and treatment.”
