Adam Blatner

In the May 26, 2009 issue (page A-13) of the Los Angeles Times, there’s an article about new trends in psychiatric diagnosis by Shari Roan, reporting from the American Psychiatric Association’s annual meeting in San Francisco. Regarding the creation of a diagnostic manual, there have been four editions, and further minor revisions: The profession of psychiatry was pressed to generate an official diagnostic manual in 1952 because of a goodly number of socio-economic and academic factors.  Prior to that, there was just a welter of different cultures, fields, names of conditions, fuzzy boundaries. This manual reflected the then dominance of psychoanalysis as a theoretical approach. In 1968, the second edition came out with many changes. (A more comprehensive story noted on Wikipedia.)  In 1980, a third edition moved it beyond psychoanalysis and sought to make it more objective. This was revised again in 1994 for the DSM-IV, and now people are working on a further revision due out around 2012. The point is that this process attempts to be fair, to include many viewpoints, and goes on for a number of years.)

Acknowledging the process of revising the Diagnostic and Statistical Manual, a variety of controversies in the field exist: What are or should be the thresholds for diagnosing a mental disorder? Are some conditions still worthy of treatment (e.g., psychotherapy, attenuation by medication) even if they don’t fully qualify according to all the criteria set out? Can there be treatment-worthy “sub-clinical” conditions? Dr. William E. Narrow, research director of the DSM-V task force, says, “In reality, there are a lot of shades of gray.” A person with four of the nine listed symptoms for depressive disorder can be more troubled and disabled than another person with six of the nine symptoms.  He says, though, that “We don’t want to take everyone who is demoralized by life and call it depression.”

The concept of “prodromal” forms—early symptoms hinting at the development of a more full-blown condition—needs to be noted. Certain conditions may respond much more readily to treatment in these early stages, but technically, may not officially be diagnosed as having a condition because there aren’t enough criteria-fulfilling signs or symptoms. This is true with certain infections, in the world of bodily illness. It may be true with such conditions as dementia, bipolar disorder, or schizophrenia. Without an official diagnosis, though, insurance companies may deny payment for treatment!

Then there are “disorders” (?) such as obesity, which clearly complicate other problems. Is overeating a disease? Under what conditions should it be considered thus, or worthy of treatment? Or is it merely a “risk” factor? When is a risk factor worthy of reimbursable treatment? (The problem with the DSM and any diagnostic system is that it operates at the interface of economics, serves a gatekeeper role for administrators who know little and care less about what a patient needs. When is it inappropriate to “medicalize” (there’s a term!) edges of the normal range of human behavior; and when is it equally inappropriate to deny treatment to people who may benefit from it?

Let it be clear at this point that I don’t believe that any diseases exist as objective entities, free of the influence of the process of social construction and definition. The question is, who to be the gatekeeper of this process and what collective agreements can we reach about policy regarding treatment?

Some conditions may be “cosmetic,” or “trivial.” Really, such terms only function as ways to differentiate between what we collectively choose to designate as significant enough to be worthy of third-party payment and those that are more an issue of voluntary agreement between client and therapist. There is also a kind of gatekeeping in the other direction, where we may collectively desire certain boards or governmental entities to evaluate and screen out treatment methods that seem grossly ineffective, possibly harmful, or in other ways incompatible with general social policy. We live in an era in which any examples I give might be used to demonstrate bias in any direction, so many issues have become controversial.

The article cites the role of Dr. David J. Kupfer, chairman of the DSM-V task force, and how he has noted that plans for the new diagnostic manual will acknowledge variations that haven’t been viewed as part of “classic” illness, and explain how conditions differ based on age, race, gender, culture, and physical health. Such moves expand the field, because previously (and still), some variations had been ignored as not fitting diagnostic criteria.

I have been put off by statistics that claim that significant percentages of the population may be diagnosed with some kind of a mental disorder. This all relates to how much, where one draws the line. As mentioned above, demoralization and situational stress generates symptoms of anxiety and depression, but that hardly constitutes the basis for a “diagnosis,” much less the institution of medication. On the other hand, I have also become impressed with the way some relatively high-functioning people can be helped to function significantly better, getting past patterns of, say, chronic irritability, by taking a low dose of some psychopharmacologic agent.

What about broadening the definition of “addiction” to include such things as shopping and going into debt, gambling, sexual adventurousness or compulsion, internet addiction? But then there’s the medico-legal problem of implying diminished responsibility if there’s any kind of “mental” or psychiatric diagnosis present—and that should not be assumed. Alcoholism is not an excuse for driving while drunk: A person should be held fully accountable for a weakness and be expected to take responsibility to avoid the temptations. Mere susceptibility to weakness is not the same as abdication of responsibility to minimize that weakness.

So many social issues involved, but so much hinges on a few key themes: What is our collective social policy going to be regarding our using collective funds, taxes, to subsidize treatment for lapses in responsibility. How much should we offer treatment to habitual overeaters, addicts, and other similar conditions? None? One chance treatment, but no relapses? Two rehabilitation programs but not more? Indefinite rescue? And so forth.

In summary, I beg the readers for a more finely nuanced appreciation of the complexities and multiple goals and concerns involved in creating or revising this book. Not to attempt to do so would be an act of denial of inadequacies evidently present; any revisions will remain controversial, though, and the final product may, like many political activities, be a compromise. The illusion that psychiatry is a science must be relinquished. It has some science involved, but even mainstream medicine is and must be to varying degrees a political, artistic, human process. In this I confess to some postmodernist tendencies. Minds interpret other minds, and this activity operates within larger cultural systems of language, meaning, and so forth. The solution is not an indulgence in the illusion that one is entitled to final truth from the so-called experts, but rather a sincere effort at improving whatever state has been achieved, a continuing dialectical process.