DSM-5 – or what are you and were they thinking?

The original DSM series was motivated by an attempt to correlate several conflicting classification schemata (such as still persist in the ICD).  However, since the American Psychiatric Association was taken over by a set of narrow specialists in neurobiology in the 1940s (Kirk and Hutchins) it has become an ever more inflexible instrument.  In general – with a few notable exceptions such as the grudging acceptance of homosexuality as normal behavior (the topic of a brilliant episode of This American Life) – each edition has been worse than the last.  The new edition promises to continue this proud trend.

Before going into some particular changes for this edition, let me rehearse two problems with the entire set.   A significant logical flaw is that it is entirely self-fulfilling: psychiatrists, psychologists and patients can only get re-imbursements for sessions attached to a specific DSM diagnosis.  There can be no disagreement with the code, even if the whole is largely flawed.  In my own experience and that of my friends, this generally means that we sit down with our psychiatrist during a session and choose a code which will do relatively little professional damage if it gets out, and will provide the drugs that she and I prefer.  I know a large number of psychologists and some psychiatrists (the non-pill-pushing variety) who find this a tad abhorrent.  Further, and again I’ll speak for myself as patient, I find the current set of available conditions massively restricting. When going through what your average Australian would call a ‘rough spot’ several years back, I was offered variously diagnoses of depression, hypermania, hypomania, manic depression, ADHD, anxiety, hyperthyroidism and anhedonism – I deeply prefer the nineteenth century offerings of melancholic, bustling, a delicate sort: each with their own social acceptance and romantic overtones. Bateson’s definition of information (a difference which makes a difference) does not obtain here, since most ascriptions of these classifications lead to the prescription of a very small set of drugs.

I am feeling ever more constrained to always keep my behavior within acceptable limits.   In the nineteenth century I could, in my Sherlock Holmes persona – but maybe I’d better not talk about that one –  fall into a black depression, shoot up some cocaine and play the violin then come out of my funk and rid the world of Moriarity.  Today, that archcriminal would quickly get me hospitalized.  In short, the medicalization of deviance – a term first deployed in the 1970s – is in its heyday.   Where the United States still manages to see itself as a haven for liberty,  I wonder how one can maintain that rosy façade in the face of the medicalization of the minds of most of our population and the largest incarceration and execution rate (the only really competing paradigm in the United States to DSM is mortal sinners vs nice people) in the developed world.

Enough of a rant perhaps.  Let’s take as given a tradition of not recognizing social, communal and family dimensions of difficult internal lives of citizens. I find it hard to be truly beatific in a world bent on ecological self-destruction and living in a society bent on unjust wars and providing no safety net for its poorest citizens so that many die unnecessarily, but I guess that’s my fault. It’s sad, but fortunately I have some happy pills.

I actually rather like the potential dissolution of Asperger’s syndrome into Autism Spectrum Disorder – despite the shocked reaction of parents of some computer geeks, who are often characterized by some forms of behavior associated with Asperger’s (just visit the Google campus for a day to verify this).  These are clearly part of a package of behaviors which run the full gamut from what should be considered normal to that which is definitely problematic.  If I had a general theory of what is called mental illness I would take this principle as a baseline: it’s spectrums all the way down.  That’s what multidimensionality is all about.  I do find some fault with Susan Swebo’s report though – what exactly does it mean to cleave to a principle that collapses without disambiguating:

How to address Pervasive Developmental Disorders – Not Otherwise Specified (PDD-NOS). The individuals currently diagnosed with PDD-NOS may still be described in DSM-V, but the work group will discuss whether they can redefine ASD in such a way that the PDD-NOS diagnosis isn’t necessary, as this diagnosis currently captures a very heterogeneous group of individuals.

If I understand the logic of this (though I’m getting depressed as I write so please don’t pay any attention to me), this means that a heterogeneous group of individuals  will become homogeneous (which basically means treated by the same drugs) if we wiggle the definition of ASD.  And this is seen as a breakthrough rather than sweeping interesting problem cases under an available carpet?

I am not totally negative about this revision.  Indeed,   I close on a somewhat hopeful note.  There are revisions being suggested to the definition of just what a mental disorder is, which include:

C    Must not be merely an expectable response to common stressors and losses (for example, the loss of a loved one) or a culturally sanctioned response to a particular event (for example, trance states in religious rituals)

D. That reflects an underlying psychobiological dysfunction

E. That is not primarily a result of social deviance or conflicts with society

If in practice we really honored C and E and defined D in some useful way (which would have to go way beyond psychobiological) then we might work towards a socially useful and culturally rich treatment of mental disorders.   First, though, the psychiatric community needs to come up with rich treatments of C and E, since currently childhood deviance or conflict is not seen in this way (even though it’s of the nature of adolescence) and the set of ‘common stressors’ and ‘culturally sanctioned’ do not include living in an overcrowded world (which we know, through rigorous study,  causes problems for rats).

Geoffrey C. Bowker

DSM V et dérives de la démocratie : quelques observations d’un clinicien inquiet

La mise en ligne des développements de la future cinquième version du célèbre manuel constitue un événement scientifique d’ampleur méritant que l’on s’y attarde parce qu’il est un observatoire heuristique d’une psychiatrisation de la vie sociale, comme la montré Lane (2009). Une brève visite du site construit par l’APA permet de se faire une idée de ce que seront les changements par rapport au DSM IV. Il m’est ici impossible de les examiner dans leur entièreté et avec la rigueur qui s’imposerait idéalement, c’est pourquoi je me centrerai sur lesdites « paraphilies » – soit littéralement les « manières d’aimer à côté » – que je connais mieux et qui me semblent paradigmatiques dans la mesure où la captation psychiatrique de la sexualité à travers le DSM pose une série de problèmes intéressants pour le chercheur en sciences humaines cliniques. Avant de m’intéresser aux paraphilies, je voudrais souligner que le terme « paraphilie » a remplacé celui de « perversion », ainsi que cela a été le cas d’autres termes comme celui de « névrose » en ce qu’ils émanaient du corpus psychanalytique. En changeant de terme, les concepteurs du manuel évacuent les débats d’école – pourtant riches et féconds – au nom du consensus politique auquel ils se sont promis d’aboutir coûte que coûte. On sait que ces mutations terminologiques traduisent l’élimination progressive des lexiques psychanalytiques, opération renvoyant à la recherche d’une légitimation d’une psychiatrie en mal de repères contre la psychanalyse (Blondiaux, 2009).

Avant d’examiner plus avant le sort réservé aux paraphilies, il me faut encore introduire une remarque substantielle sur la question de la démocratisation apparente et affichée de l’élaboration du manuel puisque tout un chacun est aujourd’hui invité à faire des commentaires sur le site web du DSM V, qu’il soit clinicien, chercheur, administrateur, malade ou parent de malade. Il est immédiatement possible d’interpréter cette offre comme relevant d’une vaste manœuvre de marketing qu’on ne pourrait manquer de relier à la rhétorique sous-jacente à l’élaboration du manuel (Kirk & Kutchins, 1998). Cette ouverture au public profane ou initié nourrit l’illusion d’une participation active à la conception d’un instrument qui les concerne : comment ne pas y voir une entrée de plus dans la psychiatrisation de la vie privée ? Les concepteurs vont-ils tenir compte des commentaires et, si oui, comment ? Se pose, selon moi, la question de la méthode et de son contrôle, à supposer bien sûr que la bonne foi accompagne l’élaboration du manuel. Et si les « feed-back » étaient effectivement considérés, seront-ils hiérarchisés ? Le commentaire d’un malade ou d’un parent a-t-il la même valeur que celui d’un chercheur ou d’un directeur d’institution psychiatrique ? Il me semble que ces questions témoignent d’une dérive de la démocratie, qu’on peut appeler le « démocratisme » (Lebrun, 2007), soit la propension de nos sociétés à développer un principe de symétrie dans le sens où tout se vaut, tout le monde a le droit au débat indépendamment de sa position dans le champ ; en quelque sorte chacun est « expert » et les différences interindividuelles ou intra-individuelles se voient lissées par une référence à l’égalitarisme juridique. De manière plus radicale, le problème de la rupture épistémologique entre sens commun et sens scientifique se pose ici avec une acuité singulière. Si la science n’est que la traduction savante du sens commun, alors elle ne mérite plus, à mes yeux, le statut de science au sens où elle devrait pouvoir développer un méta-langage susceptible d’éclairer autrement les phénomènes de sens commun.

Dans le registre des paraphilies, faisant partie des troubles sexuels et de l’identité de genre, les concepteurs de la nouvelle version réintroduisent le « trouble paraphilique coercitif » (Paraphilic Coercive Disorder) qui avait été proposé lors des précédentes révisions mais n’avait pas été adopté. Cette nouvelle entité a été proposée comme « syndrome distinct », séparé du trouble sadique sexuel (le diagnostic de trouble paraphilique coercitif exclut celui de sadisme). On parle de trouble paraphilique coercitif lorsque la personne est affligée ou détériorée par ses attirances ou a cherché la stimulation sexuelle en forçant la relation sexuelle sur trois personnes ou plus non consentantes dans des occasions séparées (je ne peux ici m’exprimer sur cette définition hautement problématique). Par le truchement de la référence au consentement, c’est le viol d’un point de vue légal qui paraît visé ainsi que semblent le confirmer les notes complémentaires faisant état de travaux menés sur des populations judiciarisées (en particulier des violeurs). On ne peut manquer de souligner l’infiltration des catégories juridiques dans le diagnostic psychiatrique aboutissant in fine à une classification hybride. De mon point de vue, la non-distinction comme l’absence d’autonomie entre les catégories juridiques et les catégories psychiatriques est non seulement une erreur épistémologique mais un véritable vecteur d’une pénalisation-psychiatrisation des populations, à grande échelle.

Cet ajout s’éclaire encore d’une autre lumière lorsqu’on le relie aux deux changements majeurs portant sur les paraphilies, lesquels affecteront le diagnostic. Il s’agit, d’une part, de l’introduction du terme « trouble paraphilique » et, d’autre part, de l’indication du nombre de victimes dont je ne traiterai pas ici. Le premier grand changement renvoie à la distinction posée entre constat d’une « paraphilie » et diagnostic d’un « trouble paraphilique ». En effet, les paraphilies ne sont pas ipso facto considérées comme des troubles psychiatriques. Une paraphilie ne réclame donc pas nécessairement une intervention psychiatrique. Est-ce l’aveu implicite que les constats pourront être posés par le quidam dans le sens d’une démocratisation des usages du DSM alors que le diagnostic ne le serait que par le clinicien ? Une définition du trouble paraphilique est donnée : ce qui cause une détresse ou une diminution de l’individu ou ce qui menace les autres. C’est donc au psychiatre de faire la part en ce qui sera un trouble et ce qui n’en sera pas un sur base d’une définition qui n’apporte que peu d’éléments. La frontière n’est donc pas claire pour décider du trouble ou non. La paraphilie est une condition nécessaire mais non suffisante pour devenir un trouble. Les concepteurs affirment que cette approche laisse intacte la distinction entre comportement sexuel normatif et non normatif pouvant intéresser les chercheurs mais ne menant pas automatiquement à considérer un comportement non normatif comme pathologique… Malgré cette nuance, pour officialiser cette position selon laquelle une paraphilie n’est pas en elle-même pathologique, les classes ont été revues : le sadisme sexuel est devenu le trouble sadique sexuel ; il en va de même des autres entités. Du reste, une paraphilie peut être considérée, dans la nouvelle version, comme « pré-pathologique » dans la mesure où les paraphilies se distinguent des « normophilies » ; au plus elles se ressemblent, au plus il faudrait de preuves pour déterminer qu’il s’agit d’une paraphilie. D’après moi, sous réserve de vérification, la « normophilie » est un nouveau néologisme exprimant qu’il est des « manières d’aimer normales » (à moins qu’il s’agisse de ceux qui aiment les normes…) et des « manières d’aimer à côté » (paraphilies) qui peuvent aussi être pathologiques (elles sont alors nommées troubles). Ce néologisme me semble faire l’aveu que les « paraphilies » sont bien du domaine psychiatrique, mordant toujours un peu plus sur le champ de la vie sociale et privée. Par conséquent, être paraphile, c’est ne pas être normal tout en n’étant pas malade… autant dire qu’il s’agit, de mon point de vue, de la définition même de ce qu’est un être humain en tension entre normalité et pathologie. Du reste, le diagnostic de paraphilie fait déjà mettre un pied dans la classification, et il y a fort à parier qu’il ne faudra que quelques efforts pour devenir malade. En fait, on peut facilement prédire que le désarroi du diagnosticien prudent ou, à l’inverse, la certitude de celui qui sait sera plus grand(e) encore qu’il ou elle ne l’était.

En conclusion, il semble bien que les « nouveaux désordres » (Disorders, traduit plus souvent par troubles) du DSM V en trahissent d’autres : épistémologiques, politiques, scientifiques… appelant à ce qu’un nouvel ordre s’établisse par la psychiatrisation et la pénalisation de la vie sociale et privée faisant de certaines de nos « manières d’aimer à côté », certes bizarres mais ni illégales ni pathologiques, de nouveaux objets de médicalisation et de judiciarisation. Ainsi, le juge et le psychiatre seront amenés à coucher dans notre lit ou à l’examiner de près. Il me semble que les dérives de la démocratie devraient pouvoir être considérées comme de nouveaux troubles, possiblement psychiatriques : la passion pour la démocratisation et le consensus devenant suspecte. Ainsi, vais-je plaider pour que le démocratisme fasse partie de la nouvelle version. Il en va de même de la coercition judiciaire ou psychiatrique forçant notre consentement à nous déterminer singulièrement, certes dans des limites qui ne sont jamais claires dès qu’il s’agit de sexualité.

Christophe Adam

BLONDIAUX Isabelle. 2009. Psychiatrie contre psychanalyse ? Débats et scandales autour de la psychothérapie ?, Paris, Le félin.

KIRK Stuart, KUTCHINS Herb. 1998. Aimez-vous le DSM ? Le triomphe de la psychiatrie américaine, Le Plessis-Robison, Synthélabo.

LANE Christophe. 2009. Comment la psychiatrie et l’industrie pharmaceutique ont médicalisé nos émotions, Traduit de l’anglais par François Boisivon, Paris, Flammarion.

LEBRUN Jean Pierre. 2007. La perversion ordinaire, vivre ensemble sans autrui, Paris, Denoël.

DSM-V: Getting Closer to Pathologizing Everyone?

For several years, the discussions about the deliberations of the various task forces involved in constructing the latest revision of the Diagnostic and Statistical Manual of the American Psychiatric Association, the DSM-V, have been shrouded in secrecy. The lack of transparency of the discussions generated highly publicized criticisms from such luminaries as Robert Spitzer, the major developer of the revolutionary DSM-III, and Allen Frances, chair of the DSM-IV task force. This situation radically changed in February with the release of the revisions of the changes proposed by the 13 work groups charged with revising the DSM.

Most of the public response to the proposed changes has centered on several alterations to particular diagnostic categories. The suggestions include using a new diagnosis of “temper dysregulation with dysphoria” for children instead of bipolar disorder, incorporating Asperger’s disorder, autistic disorder, and several other conditions into a single “autism spectrum disorders” category, and recognizing some new types of eating disorders. The focus on these specific changes, most of which are sensible, has deflected attention away from other suggestions that have much greater potential import.

Three changes, in particular, could lead to an enormous pathologization of non-disordered conditions. The first is the suggested revision of the criteria for Major Depressive Episode to remove the bereavement exclusion from this diagnosis. At present, the criteria for major depression require five or more out of nine symptoms including sadness or lack of interest or pleasure that least for at least two weeks. However, the criteria exclude people who experience these symptoms in response to bereavement: “The symptoms are not better accounted for by Bereavement” That is, people who develop enough symptoms to meet the criteria after the death of an intimate are nevertheless not defined as disordered but instead as suffering from a natural, nondisordered response to loss.

The reason for the bereavement exclusion is obvious. Voluminous evidence indicates that bereavement after the loss of an intimate is a natural reaction. The earliest literary portrayals of human experience such as Gilgamesh and The Iliad indicate that grief is a basic human emotion. Likewise, while different cultures have vastly different expressions of grief, sadness and accompanying psychological and somatic symptoms after the loss of a loved one is a universal experience. Even many primates show demonstrable signs of depression-like symptoms after the death of a close relation.  In the vast majority of cases, the universal symptoms of grief dissipate with the passage of time and only a minority of the bereaved remains highly symptomatic after several months pass.

If the suggested revision is implemented anyone who is sad, fails to derive pleasure from usual activities, finds it difficult to concentrate, and has sleep and appetite difficulties for a mere two weeks could be diagnosed with Major Depressive Disorder. Because virtually the entire population will be bereaved at some point in their lives and because such a high proportion of the bereaved would meet diagnostic criteria that require two week duration, this proposal could pathologize an enormous number of people.

A second proposal that has the promise of massively medicalizing natural emotions is to adapt dimensional assessments for the existing categorical diagnoses. On the surface, this proposal sounds sensible and desirable. Major Depression, for example, requires the presence of five symptoms but there is no natural cut-off point between four and five symptoms, or at any other particular point for this diagnosis. Depression, as well as the other major conditions in the DSM, seems to naturally be a continuous rather than a categorical condition.

The problem in dimensionalizing common conditions such as depression and anxiety is that a small number of “subthreshold” symptoms typically indicate a non-disordered condition, not a milder form of disorder. The only way to accurately use a dimensional system is to initially use criteria for disorder that separates natural from disordered conditions, regardless of how many symptoms are present. If adequate conceptions of disorder first distinguish contextually appropriate symptoms that are commonly transitory responses to stressors from mental disorders, then dimensional measurement could represent a distinct improvement in the DSM. As the discussion of bereavement indicates, however, the separation of disorders from non-disorders in the DSM-V seems to be getting worse rather than better. The current proposal to dimensionalize measures of frequently occurring disorders threatens to pathologize even mildly distressing conditions. While potentially valuable, it needs reconsideration and reformulation.

A final worrisome proposal lies in the creation of “at-risk” categories for mental disorder. At present, this possible category is limited to psychotic conditions; people who have just one symptom from among delusions, hallucinations, and disorganized speech who have never met the criteria for a psychotic disorder could receive the “at-risk” diagnosis. The diagnosis is well-intentioned and aimed at identifying people who might be at an early stage of a psychotic condition but who don’t yet meet the full criteria. Such people might benefit from early identification and treatment.

The problem with the “at-risk” category is its potential as a Trojan horse that would diagnose nearly a-symptomatic people as being in the early stages of a disorder. Yet, at present, there is no way of knowing which people with a single or a small number of symptoms will go on to meet the full diagnostic criteria and which will not. The latter group will typically outnumber the former group so that the potential for false positive diagnoses is enormous.

The current suggested revision only applies to psychotic conditions where it might not create too much damage. If it were applied to widely occurring conditions such as depression and anxiety, however, the result could be a massive amount of new pathology. For example, one of the best known studies of depression, the Dunedin Study, ties the presence of the small allele of the 5-HT gene to this condition. Yet, nearly 20% of people have two copies of the small allele and over half have one copy, so over two-thirds of the population could be viewed as “at-risk” for developing depression . Once a gene is identified as a risk factor for depression, anyone who has the gene may be a candidate for intervention, even if they don’t actually have a depressive condition. Genetic tests could identify “at risk” individuals, who could then be placed on long-term regimes of drug therapies. In the case of the 5-HT gene, a majority of people would be at risk for depression. While the DSM-V working groups have not (yet) proposed an atrisk category for depression or any other commonly occurring condition, this danger might be lurking in the future.

Overall, it appears that the original promise of the DSM-III in 1980 – the creation of a clear, precise, and reliable diagnostic system that would eventually lead to more accurate knowledge about the causes, prognoses, and treatments of mental disorders has not been fulfilled. Indeed, it is difficult to think of a single breakthrough that has resulted from psychiatry’s classificatory system. The major proposals in the DSM-V do not seem as if they will change this situation and could wind up making psychiatry’s central problem of distinguishing pathology from normality even more difficult to resolve.

Allan Horwitz

image©Vincent W. Hevern

Introducing new Resources page

H-Madness has added a new page on “Resources” (located in the toolbar at the top of the blog page). This page, which will be updated on a regular basis, includes links to syllabus archives, bibliographies,  key texts in the history of psychiatry, and case histories, as well as other materials or links of interest to teachers, students, and independent researchers. The editors welcome submissions or suggestions about new resources.

New exhibition at the Prinzhorn Museum (Heidelberg)

Recently, the Prinzhorn Collection was able to acquire with the help of the Brass foundation a unique picture series of 44 drawings. The artist, Wilhelm Werner (1898-1940), lived since 1919 in the Werneck asylum. He drew the images between 1934 and 1938, after his forced sterilisation. He transformed the experience of the degrading intervention into a series of impressively imaginative and original pictures. Two years later Werner became a victim of the Nazi “euthanasia” programme. His series of drawings is shown for the first time at the Prinzhorn Collection from the 17th of March.

International Journal of Mental Health

The most recent issue of the International Journal of Mental Health has a special section dedicated to psychiatry in France. It contains articles on the sectorization system, on users groups, on emergency psychiatry, on university psychiatry, etc.

For more information, click here.

An interview with Jonathan Metzl

Big Think, a website that publishes interviews with a wide range of experts “from hedge-fund managers to neuroscientists”, recently gave Jonathan Metzl the opportunity to resume the main points of his recent book The Protest Psychosis: How Schizophrenia Became a Black Disease.

To listen to the interview, click here.

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