Results tagged “Diagnostic and Statistical Manual of Mental Disorders” from Ψ Dare To Dream...

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Horwitz and Wakefield (2007) have released what may prove to be a highly influencial book titled The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder. The title implies that psychiatry transformed sadness into depression. It's an unfortunate catchy title that misleads the uninformed reader. Instead, the book explores in a scholarly way a fundamental principle upon which The Diagnostic and Statistical Manual (DSM) was developed.

A review of Horwitz and Wakefield (2007) by Andreea L. Seritan appeared in Am J Psychiatry 164 (11): 1764.

"The central thesis of this book is a persuasive argument that contemporary psychiatry confuses normal sadness with depressive mental disorder because it ignores the relationship between symptoms and the context from which they emerge. Although he remains cautious about the possibility of incorporating situational context into diagnostic criteria, Dr. Spitzer encourages psychiatrists to place this issue on the agenda for the upcoming formulation of DSM-V.

The book's title is a reminder of the central role of loss as a potentially severe life stressor leading to depression, as well as of how modern psychiatry is being blindsided into extrapolating most states of sadness into depression. In the first chapter, "The Concept of Depression," Drs. Horwitz and Wakefield address the move toward using descriptive criteria in diagnosing mental illness. In response to criticisms during the 1960s and 1970s about the lack of reliability of psychiatric diagnoses, DSM-III started using lists of symptoms to establish clear definitions for each disorder. The authors argue that this approach, while greatly increasing diagnostic reliability, has created new validity problems (p. 8). In the definition of major depressive disorder, DSM-III "fails to take into account the context of the symptoms and thus fails to exclude from the disorder category intense sadness, other than in reaction to death of a loved one, that arises from the way human beings naturally respond to major losses" (p. 14).

Chapter 2, "The Anatomy of Normal Sadness," discusses biologically based nonverbal expressions of grief, with emphasis on their universality across cultures and their presence in nonhuman primates and human infants prior to socialization into cultural emotional scripts (p. 39). Besides grief at the loss of a loved one, loss of meaningful relationships, loss of job or status, chronic stress, and disasters are listed as additional factors to be taken into account. Chapters 3 and 4, "Sadness With and Without Cause" and "Depression in the Twentieth Century" are a historical review of descriptions of depressive states from ancient times to the present. Disordered sadness is considered "without cause" (or "endogenous" in later terminology), as opposed to sadness "with cause" (or "reactive" sadness), which arises in people who suffer losses. Robert Burton's classic work The Anatomy of Melancholy, published in 1621, was the first to describe the three major components of depression--mood, cognition, and physical symptoms--that are still viewed as its distinguishing features. In his seminal paper Mourning and Melancholia (1917), Freud made the same distinction between mourning due to conscious losses and melancholia due to the experience of unconscious losses. DSM-III eliminated psychodynamic etiologies, instead focusing on symptoms. In large epidemiological studies, such as the Epidemiologic Catchment Area study in the early 1980s, diagnosis was based on structured tools administered by trained nonpsychiatric interviewers. The authors argue that prevalence data was skewed and advocate for a more specific screening process, as well as careful use of subthreshold diagnoses, such as minor depression.

Thoroughly documented, the first chapters caution readers about the limitations of psychiatric diagnosis. However, momentum is lost in the second half of the book. Chapter 7, "The Surveillance of Sadness," makes assumptions about psychiatric treatment that are not supported by the literature. For example, it is suggested that in primary care, "diagnosis of a depressive disorder tends to quickly foreclose...discussions in the direction of medication" (p. 156). The recent avalanche of data from the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) study suggests not only that depressed primary care patients prefer psychotherapy to medication when offered (1) but that therapy is successfully delivered in this setting, along with pharmacologic management (2). In Chapter 8, "The DSM and Biological Research About Depression," the authors again overreach, selectively analyzing individual cardinal papers and doubting their "range of applicability" without turning to the multiple evidence- based studies available in the literature (p. 176).

Although a poignant reflection on how the misapplication of psychiatric knowledge can decontextualize the lives of its patients, this book seems to miss the point that psychiatric care is a great deal more than diagnostic labeling. In practice, mental health professionals who do not rely exclusively on DSM-IV-TR use biopsychosocial formulations, viewing the individual in his or her context. Thus for many psychiatrists, treatment planning is informed by this comprehensive understanding of the person, and not solely by the description and duration of their symptoms."

Seritan has a point that many clinicians do not rely exclusively on the DSM for diagnosis. However, the classification model considered the gold standard for diagnosis DOES decontextualize diagnosis. That is a concern for training and continuing education. Given all the incentives in practice to base treatment on measurable criteria from malpractice claims, insurance payors and accreditation agencies, its very easy to slip into a comfortable criteria based practice that requires little emotional investment.

Mulder wrote an article on an even more important point about diagnosis, titled An epidemic of depression or the medicalization of distress in Perspect Biol Med. 2008 Spring;51(2):238-50.

"The syndrome of major depression is widely regarded as a specific mental illness that has increased to the point where it will be second in the International Burden of Disease ranking by 2020. This article examines the assumption that major depression is a specific illness, that it is rapidly increasing, and that a medical response is justified. I argue that major depression is not a natural entity and does not identify a homogenous group of patients. The apparent increase in major depression results from: confusing those who are ill with those who share their symptoms; the surveying of symptoms out of context; the benefits that accrue from such a diagnosis to drug companies, researchers, and clinicians; and changing social constructions around sadness and distress. Standardized medical treatment of all these individuals is neither possible nor desirable. The major depression category should be replaced by a clinical staging strategy that acknowledges the continuous distribution of depressive symptoms. Trials that test social and lifestyle treatments as well as drugs and cognitive behavioral therapy across different levels of severity, chronicity, and symptom patterns might lead to the development of a coherent evidence-based stepped treatment model."

Mulder's point is that diagnosis is a academic exercise designed to communicate a cluster of symptoms among professional colleagues. It's a model of communication. The syndromes described have acquired meaning well beyond communication. Diagnostic labels have been elevated from theoretical constructs into real phenomena. Major depression includes a cluster of symptoms that is shared by many people who are not depressed.

Wade Schuette expresses the apparent paradox of diagnosis as a prerequisite for treatment.

"If depression is largely an internal phenomenon, caused by genetics and bad wiring in the brain, that leads to one type of intervention - drugs and CBT. If depression is largely a social phenomenon, related to the well-documented collapse in social interaction documented by Putnam and the group at Duke, then personal intervention will simply deal with symptoms, and result in an ever growing prevalence of drug-dependent victims of social dysfunction - precisely the observation we find about the USA today."

The truth is all of these viewpoints have merit. Major Depression can be conceptualized and described in many ways, none of which are sufficient to explain the phenomena without considering all other viewpoints. Diagnostic categories are scientific models for communication. They are not readily amenable to measurable criteria because the concepts are complex and largely abstract constructs that fit a theory.

Sadness is an abstract concept designed to communicate a common human experience associated with grief and loss. I believe sadness is an emotion that is a critical component of a productive grief process that helps us survive and adapt to major loss. Sadness is normal and healthy. Major Depression may include sadness, maybe associated with loss, but it is a clinical syndrome that includes significant functional impairment, a loss of survival skills. Sadness is an emotional motivation that ENHANCES survival.

Finally, researchers have gotten beyond finding the "one cause" or "sure-fire cure" for the various forms of mental illness. It has always been futile to find a particular biological cause. Clinicians practicing in the field have been aware of the complexity of development. It makes much more sense to look in several directions at once, for resilience, risk factors and biologically based vulnerabilities to particular symptom clusters.

Mental illness is caused by a complicated combination of developmental and environmental stressors and biological strengths and weaknesses. Now, perhaps we can move beyond looking for the magic pill and focus on helping people.

Psychiatry Weekly

"There is a growing consensus in the field of psychiatry that many of the psychiatric illnesses, and almost certainly depression, are the product of different biological mechanisms in different patients," says Dr. Husseini Manji. "Just as hypertension and elevated blood pressure can be caused exclusively by defects in the heart, blood vessels, or kidneys, many psychiatric illnesses may have diverse causes." Dr. Manji notes that it is also not uncommon to have two patients who both meet DSM-IV criteria for depression but share no symptoms in common--one may sleep too much while the other sleeps too little, one may eat too much while the other eats too little, etc.

"It is increasingly clear that a one-size-fits-all philosophy of treatment is severely limited," Dr. Manji says. "Our group has become increasingly focused on identifying biomarkers--everything from genes and proteins to brain imaging--that are associated with particular subtypes of psychiatric illness. Accurate subtyping has a host of implications, diagnostically, but, more importantly, in terms of tailoring treatment to each individual patient.""

While still excluded from the DSM IV TR, Internet addiction has graduated to a subject worthy of research. And not surprisingly, like all other addictive behaviors, what I like to call "temporary feel goods", are associated with a lot of other diagnoses. Avoiding negative emotions has serious consequences, beyond even addictions.

CNS Spectrums

"Internet addiction were more likely to have MDD, dysthymic disorder, social phobia and adult ADHD than their unaffected counterparts. Adult ADHD is the most significant predictor for Internet addiction, followed by depressive disorders. Social phobia, however, was not correlated with Internet addiction in our sample after controlling for depressive disorders and adult ADHD. Further, depressive disorders and Internet addiction were associated in the male college students, but not the females."

There is news today of a new study about mental health problems in prison and jails. The information shows a much bigger problem than previously reported.

MSNBC.com

More than half of America's prison and jail inmates have symptoms of a mental health problem, the Justice Department estimated Wednesday. But fewer than one-third of those with problems are getting treatment behind bars. The study by the department's Bureau of Justice Statistics also found the incidence of symptoms much higher among women than men.

Compared to inmates without symptoms, these mentally troubled prisoners were more likely to have been jailed before, to get into a fight behind bars, to have been physically or sexually abused in the past and to have drug problems, the bureau said. But troubled inmates were no more likely to have used a weapon during their offense (37 percent for troubled and nontroubled state prisoners) and only slightly more likely to have committed a violent offense (49 percent of state prisoners with symptoms but 46 percent among inmates without problems).

The results are "both a scandal and national tragedy," said Michael J. Fitzpatrick, executive director of the National Alliance on Mental Illness, a national grass-roots organization dedicated to improving the lives of the mentally ill. "The study reveals that the problem is two to three times greater than anyone imagined." Fitzpatrick said the results indicate "that the mental health system is failing -- long before people enter the criminal justice system and after they leave it." He said more resources devoted to mental health treatment on the outside would avoid "enormous costs shifted onto our police, courts, jails and prisons at all levels."

[...]Fred Osher, health service policy director in the criminal justice program of the Council of State Governments, noted that previous studies that focused on those diagnosed as mentally ill found fewer troubled inmates -- closer to 20 percent.

The mental health system has been called in "crisis". The use of that term is misleading. The problem has been with us forever, we are just starting to figure out why so many people are in jail and prison. Services for mental health have always been under funded. Previous studies and a Frontline public television report prompted a previous post on this topic.

Mental health problems and criminality have common roots. I've written about this topic before.

The US has one of the highest rates of incarceration of any country in the world. At year end 2002, 1,440,655 prisoners were under the jurisdiction of State or Federal correctional authorities. Four years later, that number is estimated at 1.8 million. In 2001, about 592,000 State prison inmates were released to the community after serving time in prison. (DOJ). Of the more than half a million offenders released every year, nearly 70% of them return to prison within three years.

In reaction to the problem of the "career criminal", the states and federal legislators passed tough new mandatory sentencing laws. The prison population as a result has grown precipitously. Now virtually every prison in the US is overcrowded. There is evidence that overcrowding "creates competition for limited resources, aggression, higher rates of illness, increased likelihood of recidivism and higher suicide rates." In addition, the cost of incarcerating an ever increasing population is skyrocketing, for the most part made up of non-violent offenders.

[...]We live our lives based on experiences we've had over our lifetime and the skills we learn and abilities with which we are born. People who behave in anti-social ways have learned that this behavior has advantages over socially acceptable behavior. Many of the studies reviewed in Hare's book reflect a poor relationship between parent and child, an absent or ineffective father figure, and abusive, inconsistent and/or neglectful child rearing. Children who grow up anti-social witness a disproportionate level of violence and perhaps most importantly, a level of chaos and absence of a perception of fairness and justice in their lives. They learn that their behavior in the long run doesn't change anything, delay of gratification just produces more pain. So short-term gain is chosen as the primary motivator. And the child's own self-interest is considered above all other considerations.

The study, by the Bureau of Judicial Statistics, a division of the Department of Justice, is done periodically. Previous reports found focused on only previously diagnosed inmates finding only 20%, similar to the current study based on recent history. The new study suggests that inmates are overwhelmingly under diagnosed. That's not particularly surprising since much so called "criminal behavior" is also associated with mental illness. An untrained eye in law enforcement is not likely to see what are often subtle differences that could only be verified by a formal diagnostic assessment by a mental health professional experienced in forensic mental health. Here are some key excerpts from the study:

At midyear 2005 more than half of all prison and jail inmates had a mental health problem, including 705,600 inmates in State prisons, 70,200 in Federal prisons, and 479,900 in local jails. These estimates represented 56% of State prisoners, 45% of Federal prisoners, and 64% of jail inmates. The findings in this report were based on data from personal interviews with State and Federal prisoners in 2004 and local jail inmates in 2002. Mental health problems were defined by two measures: a recent history or symptoms of a mental health problem. They must have occurred in the 12 months prior to the interview. A recent history of mental health problems included a clinical diagnosis or treatment by a mental health professional. Symptoms of a mental disorder were based on criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).

• More than two-fifths of State prisoners (43%) and more than half of jail inmates (54%) reported symptoms that met the criteria for mania.


• About 23% of State prisoners and 30% of jail inmates reported symptoms of major depression.


• An estimated 15% of State prisoners and 24% of jail inmates reported symptoms that met the criteria for a psychotic disorder.


• Female inmates had higher rates of mental health problems than male inmates (State prisons: 73% of females and 55% of males; local jails: 75% of females and 63% of males).


• About 74% of State prisoners and 76% of local jail inmates who had a mental health problem met criteria for substance dependence or abuse.


• Nearly 63% of State prisoners who had a mental health problem had used drugs in the month before their arrest, compared to 49% of those without a mental health problem.


• State prisoners who had a mental health problem were twice as likely as those without to have been homeless in the year before their arrest (13% compared to 6%).


• Jail inmates who had a mental health problem (24%) were three times as likely as jail inmates without (8%) to report being physically or sexually abused in the past.


• Over 1 in 3 State prisoners and 1 in 6 jail inmates who had a mental health problem had received treatment since admission. State prisoners (18%), Federal prisoners (10%), and jail inmates (14%) most commonly reported that they had used prescribed medication for a mental problem in the year before arrest or since admission.


• To meet the criteria for major depression, inmates had to report a depressed mood and decreased interest or pleasure in activities, along with 3 additional symptoms of depression. In order to meet the criteria for mania, inmates had to report 3 symptoms during the 12-month period. For a psychotic disorder, 1 symptom of delusions or hallucinations met the criteria.


• About half reported a family member incarcerated, 15% higher rate than none MI.


• Past physical or sexual abuse more prevalent among inmates who had mental health problems State prisoners who had a mental health problem (27%) were over two times more likely than those without (10%) to report being physically or sexually abused in the past. Jail inmates who had a mental health problem were three times more likely than jail inmates without to have been physically or sexually abused in the past (24% compared to 8%).


• Among State prisoners who had a mental health problem, nearly half (49%) had a violent offense as their most serious offense, followed by property (20%) and drug offenses (19%) (table 8). Among all types of offenses, robbery was the most common offense (14%), followed by drug trafficking (13%) and homicide (12%). An estimated 46% of State prisoners without a mental health problem were held for a violent offense, including 13% for homicide and 11% for robbery. About 24% of State prisoners without a mental problem were held for drug offenses, particularly drug trafficking (17%).


• Almost an equal percentage of jail inmates who had a mental health problem were held for violent (26%) and property (27%) offenses. About 12% were held for aggravated assault. Jail inmates who had a mental health problem were two times more likely than jail inmates without a mental problem to be held for burglary (8% compared to 4%). Use of a weapon did not vary by mental health status.


• The proportion of State prisoners who had used prescribed medication for a mental health problem since admission to prison rose to 15% in 2004, up from 12% in 1997 (table 15). There was little change in the percentage of inmates who reported an overnight stay in a hospital since admission (around 3%), or in the percentage who had received professional mental health therapy (around 12%).

Three-quarters of female inmates in State prisons who had a mental health problem met criteria for substance dependence or abuse. Female State prisoners who had a mental health problem were more likely than those without to --

• meet criteria for substance dependence or abuse (74% compared to 54%),


• have a current or past violent offense (40% compared to 32%),


• have used cocaine or crack in the month before arrest (34% compared to 24%),


• have been homeless in the year before arrest (17% compared to 9%).


• report 3 or more prior sentences to probation or incarceration (36% compared to 29%),


• report past physical or sexual abuse (68% compared to 44%),


• report parental abuse of alcohol or drugs (47% compared to 29%),


• report a physical or verbal assault charge since admission (17% compared to 6%).

The study report also included baseline information about mental health problems in adults for comparison purposes. Here is a summary:

As I said, the problem is not new, the recognition of the problem is an encouraging sign. The news reports quote the need for better mental health services to prevent crimes. That would certainly help. But the problem is bigger than that. From another previous post on the topic:

The US has one of the highest rates of incarceration of any country in the world. At year end 2002, 1,440,655 prisoners were under the jurisdiction of State or Federal correctional authorities. Four years later, that number is estimated at 1.8 million. In 2001, about 592,000 State prison inmates were released to the community after serving time in prison. (DOJ). Of the more than half a million offenders released every year, nearly 70% of them return to prison within three years.

In reaction to the problem of the "career criminal", the states and federal legislators passed tough new mandatory sentencing laws. The prison population as a result has grown precipitously. Now virtually every prison in the US is overcrowded. There is evidence that overcrowding "creates competition for limited resources, aggression, higher rates of illness, increased likelihood of recidivism and higher suicide rates." In addition, the cost of incarcerating an ever increasing population is skyrocketing, for the most part made up of non-violent offenders.

[...]Children who grow up anti-social witness a disproportionate level of violence and perhaps most importantly, a level of chaos and absence of a perception of fairness and justice in their lives. They learn that their behavior in the long run doesn't change anything, delay of gratification just produces more pain. So short-term gain is chosen as the primary motivator. And the child's own self-interest is considered above all other considerations.

Much the same could be said about people who grow up with mental health problems. The rates of child abuse and neglect due to chemical abuse by parents, and a chaotic lifestyle leads to the next generation at risk. From a previous post:

The correctional system we have is a complete failure. The only thing that works is locking people up for life. Truly, we as a society can't afford to lock up more than 2% of our total population at any one time. We need another solution. Career criminals are seldom caught. When they are, it's after more than a dozen offenses. Punishment will never be assured because we can't afford to lock them all up. We need a solution to the problem, not an over-sized band-aid.

The problem of crime [mental illness] and drug abuse originates in childhood. Years of research has shown that parents with chaotic lifestyles produce children with chaotic futures. Until we improve our parenting skills across the board, we will have to live with incredible crime and incarceration rates. We need to be teaching parents-to-be the skills beginning in junior high rather than assuming that parents pass on this skill to their children. Teaching parents-to-be how to nurture a quality attachment their children is critical. But it is also necessary to train parents-to-be emotion management skills and how to systematically teach those skills to their children. Competent parenting requires knowledge about emotion management and how to solve behavioral problems. My local school includes "Character Education" in it's curriculum. Creative approaches can be acceptable to both sides of the political spectrum. Improving parenting skills is critical to retrieving what has become a chronic underclass living a chaotic drug infested lifestyle.