By Jonathan Bauman, MD, LFAPA
Newsletter Editor
"Life is Nasty, Brutish, and Short" — Thomas Hobbes
My first diagnostic manual was DSM-II, a yellow, spiral bound, soft-cover
book about a half-inch thick. One could pretty well memorize the content,
as did I and my colleagues in mid-1970’s residency training. The manual
contained 182 disorders in 134 pages of text.
A few years later, when it was decided that DSM-II was not “scientific”
enough, a much larger, heavier tome — DSM-III — was released by the
APA, allegedly to improve the reliability of psychiatric categorizations.
Diagnosis was now to be based on observable signs and symptoms rather
than assumptions of causality. With publication of this “breakthrough”
compendium, the number of psychiatric disorders increased to 265 in 494
pages. Then, a few years later, the number of diagnoses in the revised
volume (DSM-III-R) jumped to 292 in 567 interesting pages of reading.
Unfortunately, however, the reliability of psychiatric diagnosis did not
improve.
In 1994, DSM-IV was published with various “improvements” including the
5-part multi-axial system, a crosswalk to the ICD coding system, and the
requirement that a disorder cause “significant distress/impairment in
important areas of functioning (social, occupational, etc.)”. Diagnoses
ballooned to 410 disorders in a svelt 886 pages, but the reliability of
diagnosis continued to remain wanting, even after publication of a text
revision (DSM-IV-TR) in 2000.
In 2013 the APA decided to simplify diagnosis by eliminating Roman
numerals in favor of the more common Arabic system in its release of
DSM-5. In this edition some diagnoses were broadened while other’s
were narrowed. For example Asperger’s Disorder was subsumed under
Autism Spectrum Disorders, of a mild variety. This was a wise decision as
Dr. Asperger was a Nazi sympathizer during WW-II who promoted the
extermination of autistic children. DSM-5 had some text revisions in 2022,
so it’s now DSM-5-TR. The number of discreet diagnoses is
approximately 600 in around 1000 discreet pages. And guess what...the
reliability of psychiatric diagnosis has still not improved.
Personally, during my years of practice, I found the sheer numbers of
psychiatric diagnoses an embarrassment for our profession. I wasn’t
alone with this belief, as many of my colleagues felt the same way.
Certainly most of you are familiar with the work of Allen Frances in this
regard. As the threshold for diagnosis of psychiatric disorders gets lower
and lower, thereby increasing their prevalence, how much room is left for,
as Freud called it, ordinary human misery? In a world where untold
numbers of inhabitants live nasty and brutish lives, how many would not
qualify for a psychiatric diagnosis? If everyone suffers with something,
then who doesn’t suffer with anything? And with all the focus on
diagnosis, the unspoken truth — well, I’ve spoken about it with colleagues
— is that we don’t treat diagnoses, we treat symptoms.
So maybe we are trying to fit square pegs into round holes. This seems to
be an apt metaphor if we think of the sharp edges of a square peg as
similar to the physical signs, blood tests and imaging studies in other
areas of medicine, whereas the symptoms and behaviors of psychiatric
patients are like the softer edges of a round hole. While researchers have
sought the holy grail of medically reliable and valid psychiatric diagnosis
(square peg) over many years, it remains out of reach because much of
what we deal with in psychiatry is subjective (round hole) on the part of
both patients and clinicians.
The development of the DSM suits the needs of researchers and other
users. Heath insurance companies use it to limit care and costs, chasing
the increasing number of diagnosable patients who qualify for services.
Pharmaceutical companies continue to expand advertising and increase
revenue by pandering to sufferers of questionable disorders. How many
moody people are seeking meds for their “bipolar depression”, unhappy
people for their “treatment resistant depression”, or distractible people for
their “adult ADHD”? And here’s one for you. Recently, Eco-Anxiety, i.e,
anxiety about climate change, has appeared in the literature. Will this be
another diagnosis added to the DSM?
We are all aware of the the explosion of anxiety and depression in
teenagers in recent years. In a recent NYTimes video entitled “High
Functioning Anxiety Isn’t a Medical Diagnosis...It’s a Hashtag”, Lucy
Foulkes, an academic psychologist at Oxford University, argues that much
of this crisis in mental health is a product of teens being flooded on the
internet with too much awareness of signs and symptoms of anxiety and
depression, often unreliable. This sets up a vicious cycle of over-
awareness leading to over-interpretation, leading to over-diagnosis of
mental illness — a self-fulfilling prophecy — rather than feelings being a
normal part of adolescent experience. Foulkes doesn’t dismiss the
distress that many adolescents are feeling, but she does caution care in
our diagnosis and treatment of our patients. Will “High Functioning
Anxiety” be yet another diagnosis in DSM-6?
Let’s be honest, the DSM can also be used to convince ourselves that
psychiatry is like any other medical science. How many of us are
augmenting drug trials with another medication, ketamine or TMS when a
quick fix for “treatment resistant depression” or “bipolar depression” fails?
How many of us have the time to really get to know our patients and what
ails them? The FDA recently approved an app, available by prescription,
for patients already on an antidepressant but needing augmentation. The
app apparently has some beneficial effect, but not any more than a sham
app. I can’t help but wonder exactly how depressed the subject patients
were, or whether they suffered from Major Depression at all. And how
much money does the app developer expect to make?
To my thinking, people can benefit from treatment, whether for ordinary
human misery (high functioning anxiety) or extraordinary human misery
(mental illness). Problem is, the time and money it takes to provide skillful
psychotherapy and knowledgable medication treatment is often not readily
available, nor are the social programs necessary for successful treatment
of our sickest patients.
I can’t ignore what appears to me to be a dialectical dilemma for our
profession. If, as diagnoses proliferate, everyone qualifies for a psychiatric
diagnosis, does everyone qualify for insurance or government-provided
treatment? Do we advocate for more treatment that can’t be paid for?
Certainly those suffering from “ordinary human misery” can pay for
treatment if they can afford it, and they often do. Most people, however,
don’t have this luxury and deal with their distress in, too often, destructive
ways. How, as a society, do we reach them? How do we put the “social”
back in “bio-psycho-social”? Can we ever make life less nasty, brutish
and, for some, short?
