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Commentary

Psychiatry’s Conceptual Malpractice

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NEW YORK – The American Psychiatric Association’s recent proposed changes to its official diagnostic manual – the Diagnostic and Statistical Manual of Mental Disorders (“DSM”), often called the “bible of psychiatry” – may discredit psychiatric diagnosis more than improve it. The DSM specifies the symptoms by which every mental disorder is diagnosed, in effect defining what is psychologically normal and abnormal in the United States – and, increasingly, for much of the rest of the world as well.

Revising the DSM’s diagnostic criteria for the upcoming fifth edition (“DSM-5”) is a heavy responsibility. Draw the line between normality and disorder too broadly, and individuals may suffer incorrect diagnoses and undergo needless and potentially harmful treatment. Indeed, the DSM’s history reveals many such errors of over-inclusiveness.

But if the line is drawn too narrowly, individuals may not get needed help. Although psychiatrists tend to worry more about identifying potential patients in need of help and less about eliminating normal eccentricity and distress from diagnosis, it is crucial in any society that respects human variation and encourages individual moral responsibility to distinguish normal suffering and eccentricity from mental disorder.

These are delicate issues of conceptual analysis. Yet the psychiatrists who formulated the DSM-5’s proposed changes are not trained in conceptual analysis, and, though amply forewarned, they have addressed the normal-versus-disordered issue in an unsystematic, ad hoc manner. The result is a form of conceptual malpractice: intellectual negligence resulting in the formulation of invalid diagnostic criteria that will misdiagnose normal individuals as disordered.

Consider the following proposed new disorders:

(1)   Binge eating disorder. If you overeat once a week for three months, lacking self-control and experiencing over-fullness afterward, and are distressed, embarrassed, and disgusted with yourself, you are diagnosable. Apparently, people who feel bad about not being fully controlled in their eating when confronted by weekend buffet-style feasts are disordered.

(2)   Hoarding disorder. If you resist discarding possessions that others (a spouse, say, or a clinician) find of limited value, and consequently clutter your living space, and you are distressed about this or are creating what others consider an unsafe environment, you are diagnosable. This category will be welcomed by neatniks irritated by acquisitive partners.

(3)   Hypersexual disorder. If you are highly sexual for six months in a way that feels uncontrolled and becomes distressing, and use sexuality for relieving feelings of stress and boredom or without consideration of the emotional effect on others (formerly known as being a “cad”), you are diagnosable. This disorder presumes that using sex to relieve unhappiness, and feeling guilty about it, is also diagnosable.

Other proposed DSM-5 changes open the door to future abuses. “Pathological gambling” would be placed in a new super-category of “behavioral addictions,” opening the way for “internet addiction” and many other behaviors to be deemed pathological.

Likewise, loose or quirky thinking that is not now a disorder but indicates an increased risk of developing a psychotic disorder would be classified as a “psychotic risk disorder.” Those diagnosed with this condition would be more likely to be treated with potent drugs, though most never develop a psychotic disorder – setting a precedent for confusing risk factors with actual disorders.

Other changes undermine the validity of existing categories. For example, the DSM currently distinguishes substance dependence – essentially addiction (a disorder) – from substance abuse, a weaker category that includes dubious criteria such as driving while intoxicated or arguing with others about substance use. The DSM-5 proposes to eliminate the weak “abuse” category, but only by combining its misconceived criteria with current dependence criteria to form a unified “substance use disorder” category, and reducing the number of symptoms needed for diagnosis from three to two.

As a result, substance dependence would disappear as a valid category. Under the proposal, if you occasionally drive your car home from parties after drinking and argue with your spouse about it afterwards, you would have alcohol-use disorder. The vacuity of the abuse category will now infect the dependence category.

A second example: it has been known since antiquity that normal people who recently experienced a significant loss – especially of a loved one – can have the same symptoms (e.g., sadness, insomnia, fatigue, loss of interest in usual activities, lessened appetite) as those indicating major depressive disorder. Thus, the DSM currently eliminates the recently bereaved from depression diagnosis unless they have certain extreme symptoms suggesting more than intense grief.

By contrast, the DSM-5 proposes to eliminate the bereavement exclusion. Anyone with depressive symptoms for just two weeks after suffering a significant loss would be diagnosed with major depressive disorder, massively pathologizing normal intense grief.

Moreover, some obviously invalid current categories have not been addressed. For example, if you are sad for two weeks and have one other related symptom, such as fatigue, insomnia, or lessened appetite, and you are distressed or impaired at work or in other roles, then you have “subsyndromal depression.” But research shows that virtually anyone with two weeks of sadness feels distressed and is likely to be role-impaired, so in effect this category elevates moderately prolonged normal sadness into a mental disorder.

All the above categories encompass some genuine disorders. The problem is that the criteria are drawn so broadly that they pathologize mostly the non-disordered. Normal individuals often need and deserve help, but the decision as to the kind of help they get should not be biased by incorrect labeling of their conditions as mental disorders that suggest something is internally wrong with them.

The current symptom-based diagnostic system was developed partly to answer criticism that psychiatry is just social control of undesirable behavior dressed up as medicine. By failing to distinguish adequately normal distress and eccentricity from disorder, the DSM-5’s proposals threaten to increase dramatically the types of abuses that the DSM was designed to prevent. Another anti-psychiatric backlash may not be far behind.

Jerome C. Wakefield is Professor of Social Work and Professor of Psychiatry at New York University and author (with Allan V. Horwitz) of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. Copyright: Project Syndicate, 2010. www.project-syndicate.org

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