Tuesday, July 14, 2015

The power of a name: Controversies and changes in defining mental illness

by Carlie Hoffman

The purposes of naming are to help categorize the world in which we live and to aid in grouping similar things together. However, who decides which name is the correct one? Is a child who often cannot pay attention to his classwork “absent-minded,” or experiencing attention deficit hyperactivity disorder? Is a person whose moods often swing from one extreme to the other simply “moody,” or living with bipolar disorder? Naming a lived experience a “mental illness” has the ability to change the social realities of those who receive the diagnosis, altering not only self-perception, but also influencing the perceptions and triggering the biases of others— often in a detrimental manner. So, who has the power to determine how such a label is assigned, and what happens if someone is given the wrong one?

The power affiliated with naming has caused the diagnosis of mental disorders to be fraught with controversy. Mental illnesses are defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM), which has been deemed the “bible” of mental health. According to Dr. Thomas Insel, the director of the National Institutes for Mental Health (NIMH), the goals of the DSM are to create a common language for describing mental illness, and to ensure that mental health care providers use the same terms in the same ways. Thus, when patients visit a psychiatrist in search of a name that will define the symptoms they are experiencing, this name is assigned with the aid of the DSM.

One controversy affecting the diagnosis of mental disorders is the growing concern with medicalization of the “normal” human experience. Medicalization is the process of defining select human experiences or conditions, typically ones that were once considered normal, as medical conditions that warrant professional medical attention. Some level critiques against medicalization, particularly the medicalization of experiences associated with cognitive and emotional function, suggesting it can lead to over-diagnosis of mental disorders as individuals cope with stressors in a typical fashion [5, 11, 13]. A series of controversial changes made to the newest edition of the DSM, DSM-5, have provided a foothold for those concerned with medicalization. The addition of premenstrual dysphoric disorder and the elimination of the bereavement exclusion from the criteria for major depressive disorder have increased the apprehension that typical premenstrual mood and behavioral changes, and the normal grieving process could be classified as mental disorders [7, 13, 14].

An additional problem arises in the difficulty of conceptualizing a “typical” example of a person with any given disorder. The high level of heterogeneity present within individuals with the same mental illness insinuates that two people diagnosed with “major depressive disorder” can experience very different symptoms. Therefore, being assigned the blanket diagnosis of “depression” is relatively uninformative and consequently, such mental disorders are difficult to treat and research. Furthermore, a diagnosis can bring with it social, financial, and political stigmas that may have a huge impact on the patient’s quality of life and self-concept [3, 4, 16]. These stigmas against the mentally ill may also be influenced by the variability present among those diagnosed. Individuals with mental disorders express a wide range of symptom type and severity, which frequently leads to people thinking the worst of those diagnosed with a mental illness, often through invalidating someone’s lived experience or grossly misunderstanding their symptoms. This misconception leads to further stigma as people erroneously apply exaggerated stereotypes to all diagnosed individuals, regardless of the truth of the stereotype. One such example is the belief that those with mental illness are more violent than undiagnosed individuals (see previous related blog post here).

The DSM has undergone several revisions since its first publication by the American Psychiatric Association (APA) in 1952 with the goal of gathering statistical information from mental hospitals. The first edition of the DSM (DSM-I) included 106 disorders, called “reactions.” The use of this term reflected the influence of the psychodynamic view held by Adolf Meyer, who felt mental illness was the byproduct of the body’s reaction to life circumstances and emotional distress [2, 8]. The publication of DSM-II in 1968 saw the addition of 76 disorders and the elimination of the term “reaction,” which removed the influence of psychodynamic theory from mental illness diagnosis. In 1980, DSM-III expanded to include 265 disorders and started to become a tool for clinicians and researchers instead of simply functioning as a statistical manual. DSM-IV was published in 1994 and included more than 300 disorders, and finally the most recent version of the manual, DSM-5, was released in 2013 [2, 15].

DSM-5 is perhaps the most controversial edition of the DSM, and sports significant changes to the criteria for several disorders— to the chagrin of the public, mental health practitioners, and the field of psychiatry at large. Prominent controversies center on the expansion of many diagnostic criteria seen in previous DSM editions, including the combination of four separate disorders (autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified) into one diagnosis of Autism Spectrum Disorder [1, 6], and the removal of the bereavement exclusion criteria from the major depressive disorder diagnosis. This removal allows individuals coping with the recent loss of a loved one to be diagnosed with major depression [13, 14]. There is also concern as to the motives behind these changes, with some critics claiming conflicts of interest and ties to drug companies may have driven the alterations [12, 13]. A 2012 article in The Washington Post described the increasing shift toward prescribing antidepressant medications for those grieving the loss of a loved one. The article also stated this shift was largely instigated by individuals affiliated with pharmaceutical companies: eight of the eleven APA members who drove this change had economic conflicts of interest with drug companies, and a key advisor of the APA committee was the first author of a study evaluating the efficacy of antidepressant medications on grieving individuals.

While DSM-5 is portrayed as the objective gold standard all psychiatrists are expected to utilize, the disorders it describes are ultimately determined by an educated, but subjective, collective opinion. In total, more than 160 individuals were involved in the creation of DSM-5, including nearly 100 psychiatrists, 47 psychologists, two pediatric neurologists, three epidemiologists, one pediatrician, one social worker, and one psychiatric nurse [2]. However, even with such capable contributing members, the diagnostic criteria within DSM-5 were still ultimately decided by subjective opinions, and not objective definitions. Consequently, without more objective or qualitative standards for each mental disorder, diagnostic criteria can, and have, changed over time from DSM-I to DSM-5. Key examples, as described in the Los Angeles Times, include homosexuality, which was considered to be a mental disorder until it was removed from the DSM during a revision in 1974; and PTSD, which was not formally recognized as a disorder until 1980. This weakness of the DSM was described by Dr. Thomas Insel as a lack of validity: diagnoses are based on an agreement about symptoms and not on any objective measures. In essence, “this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever” [10].

However, the subjectively-defined tides of mental illness are beginning to change, and steps are being made to remedy the variable nature of mental disorder diagnosis. The NIMH published a Strategic Plan in 2008 with the goals of defining the mechanisms of complex behaviors, charting the trajectories of mental illness, striving for cures and prevention, and promoting progress in basic and clinical research of mental disorders. In 2013, months prior to the release of DSM-5, Dr. Insel also discredited the DSM and the symptom-based method of mental disorder diagnosis, claiming “it is critical to realize that we cannot succeed if we use DSM categories as the ‘gold standard’” [10]. Following this comment, he also introduced a new direction for NIMH-funded research that aligned with the goals of the Strategic Plan, called the Research Domain Criteria (RDoC) project. RDoC is a decade-long project with the goal of incorporating more objective tools, such as those offered by genetics, cognitive science, and brain imaging, into the criteria for mental disorder diagnosis [9]. While this appears to be a step in the right direction and the entrance into a new era for mental illness, RDoC is still in its infancy. This initiative will hopefully produce more objective and improved systematic means for defining mental disorders.

Nevertheless, because mental illnesses are highly variable and do not have a uniform cause or course, the diagnosis of many of our most common mental illnesses will continue to rely on subjective assessment: at some point in the diagnostic process, the decision of whether to assign a diagnosis will involve the opinion of the health care professional. Though not ideal, the DSM has helped standardize this process and represents a much-needed attempt to ground the subjectivity of mental illness in the collective of numerous psychiatrists through the use of systematic analysis. While RDoC seeks to create a new standard for the field and may serve to usher in an era of improved objectivity and better research targets, it is likely that subjectivity will remain to some extent in the diagnosis of the mentally ill. Yet, the main vice associated with mental illness diagnosis is not just the subjectivity of the DSM naming system, but also the misguided public perception of the mentally ill. While use of the DSM may lead to an inaccurate diagnosis, the main negative repercussions of such a diagnosis arise from uninformed public opinion and stigma. Thus, the road to improving the field of mental illness is twofold: reducing the subjectivity inherent in the criteria used to define mental disorders, and improving the appreciation society has for mental illness to reduce stigma and make the world more hospitable for those with mental illness and those in pursuit of mental health.

Works Cited

1. American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition. Arlington, VA: American Psychiatric Publishing.

2. American Psychiatric Association (2015) DSM: History of the Manual. Retreived from: http://www.psychiatry.org/practice/dsm/dsm-history-of-the-manual

3. Corrigan PW (2014) Erasing stigma is much more than changing words. Psychiatr Serv 65: 1263-1264. doi: 10.1176/appi.ps.201400113

4. Corrigan PW, Mittal D, Reaves CM, Haynes TF, Han X, Morris S, & Sullivan G (2014) Mental health stigma and primary health care decisions. Psychiatry Res 218: 35-38. doi: 10.1016/j.psychres.2014.04.028

5. Graf WD, & Singh (2015) I Can Guidelines Help Reduce the Medicalization of Early Childhood? The Journal of Pediatrics. doi: http://dx.doi.org/10.1016/j.jpeds.2015.03.049

6. Harstad EB, Fogler J, Sideridis G, Weas S, Mauras C, & Barbaresi WJ (2014) Comparing Diagnostic Outcomes of Autism Spectrum Disorder Using DSM-IV-TR and DSM-5 Criteria. J Autism Dev Disord. doi: 10.1007/s10803-014-2306-4

7. Hartlage SA, Breaux CA, & Yonkers KA (2014) Addressing concerns about the inclusion of premenstrual dysphoric disorder in DSM-5. J Clin Psychiatry 75: 70-76. doi: 10.4088/JCP.13cs08368

8. Houts AC (2000) Fifty years of psychiatric nomenclature: reflections on the 1943 War Department Technical Bulletin, Medical 203. J Clin Psychol 56: 935-967.

9. Insel TR (2014) The NIMH Research Domain Criteria (RDoC) Project: precision medicine for psychiatry. Am J Psychiatry 171: 395-397. doi: 10.1176/appi.ajp.2014.14020138

10. Insel T (2013) Transforming Diagnosis. Director’s Blog. Retrieved from: http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml

11. Kontaxakis V, & Konstantakopoulos G (2015) From DSM-I to DSM-5. Psychiatriki 26: 13-16.

12. Moynihan RN, Cooke GP, Doust JA, Bero L, Hill S, & Glasziou PP (2013) Expanding disease 
definitions in guidelines and expert panel ties to industry: a cross-sectional study of common conditions in the United States. PLoS Med 10: e1001500. doi: 10.1371/journal.pmed.1001500

13. Nonino F, & Magrini N (2014) [DSM-5: a diagnosis and a drug should not be denied to anyone]. Recenti Prog Med 105: 51-55. doi: 10.1701/1417.15696

14. Pies RW (2014) The Bereavement Exclusion and DSM-5: An Update and Commentary. Innov Clin Neurosci 11: 19-22.

15. Tartakovsky M (2011) How the DSM Developed: What You Might Not Know. World of Psychology. Retrieved from: http://psychcentral.com/blog/archives/2011/07/02/how-the-dsm-developed-what-you-might-not-know/

16. Torrey EF (2011) Stigma and violence: isn't it time to connect the dots? Schizophr Bull 37: 892-896. doi: 10.1093/schbul/sbr057

Want to cite this post?

Hoffman, C. (2015). The power of a name: Controversies and changes in defining mental illness. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2015/07/the-power-of-name-controversies-and_6.html

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