Thomas Insel, director of the US National Institut of Mental Health (NIMH), recently criticized the new edition of the DSM, the classification of mental illnesses of American psychiatrists, called “the bible of psychiatry”, forcing David Kupfer, director of the revision of the DSM-5, to officially respond to criticism 1,2.
The news was published in several important newspapers that commented and pushed to various analyzes 3,4,5.
Even more ferocious are the criticisms of the psychiatrist Allen Frances who led the revision of the fourth edition of the manual 6. These further criticisms come shortly before the official presentation of the DSM at the annual Congress of American psychiatrists 7.
“But how did we get to this point
“ asks a French colleague …
I try to answer him by reconstructing the history of DSM and diagnosis in psychiatry.
As the medical community questions brain diseases and discusses their definition and classification, people talk about dreams, emotions, wrongs and traumas. Last night I dreamed of falling … Yesterday my employer was rude, I hope he doesn’t want to fire me … As a child they scolded me … At school they made fun of me … Last year my mother died … All natural problems related to the human condition: it is really necessary to talk to the psychiatrist
The search for a cause for existential malaise has always conditioned the concept of mental illness and the acceptance that a condition of illness of the soul could exist. There are emotions, thoughts, behaviors, but they cannot be prey to disease, only life can have a favorable or unfavorable outcome and affect our mood.
Those who think in these terms do not accept that the mind can be sick and will tend to deny mental illness by attributing to the outside the temporary cause of the discomfort. For others, however, it is a question of human conditions that cannot be defined as a disease. This is what many psychologists (and some psychiatrists) think and those who accuse American psychiatrists of wanting to medicalize normal human suffering 8,9,10.
What if it were the opposite
That is that our mindset also conditions the unfolding of events and our interpretation of
the
same it is necessary to continue reading this text and you can leave the blog.
If, on the other hand, you think that the brain is an organ that can get sick and that mental, emotional, relational life and thought with associated behaviors can get sick, you will admit that the resulting diseases to be treated must be studied and therefore also classified according to to current scientific knowledge.
In the case of mental illnesses, as for many other medical affections, in the absence of sufficient biological knowledge to define the disease according to anatomical- and physio-pathological terms, we still resort to pure clinical knowledge, that is the observation of phenomena and their definition and classification.
The difficulty in knowing the normal (read: physiological) functioning of the human brain, ie the knowledge of normality, makes it more difficult and controversial to define what is abnormal. Think for example of mourning. It is one of the most common human events and shared in all parts of the globe and not just among human beings. Culturally, man has created rites (various funeral ceremonies and the cult of the dead) to overcome this trauma. The fact that it is a universal, inevitable, painful experience, and accepted by all societies, determines its character as a natural event that should not be considered pathological. This is one of the issues that divides the psychiatrist community: bereavement is a disease
One of Allen Frances’s criticisms is that with DSM-5 there will be an increase in diagnoses of depression within 2 weeks of the death of a loved one, medicalizing, stigmatizing and unnecessarily treating a natural condition. Let’s change perspective for a moment. In my hospital clinic practice I deal with bereaved people who come to my attention months or years after the event or after a suicide attempt. Suicide due to bereavement is normal
Being sick for years after bereavement is normal
This is illness
Let’s let the experts and non-experts discuss it …
Established that there are abnormal behaviors (which come out of a norm), these can be classified according to discrete elements (categories) or fluidly (dimensions). Gia Plato and Aristotle had posed the problem of the existence of diseases with a clear separation between normal and pathological (Plato) or with more blurred boundaries (Aristotle). Nowadays the classification by categories prevails with clear limits between normality and pathology. This is another source of criticism: the normal-pathological dichotomy would not lend itself well to the human condition and therefore to mental suffering. Therefore the categorical diagnosis is not good because it would be an attempt to medicalize normal behaviors.
In reality, things are not that simple and the psychiatric community has been discussing categories and dimensions for decades and the diagnoses as well as the statistics are quite elastic and malleable in defiance of all the DSMs in the world. It is therefore a fallacious argument.
There are two classifications known to the international scientific community.
The first is that of the World Health Organization (WHO – WHO) which is called ICD-10 (International Classification of Diseases) now in its tenth edition and which deals with classifying all existing diseases into codes, including a chapter dedicated to diseases mental.
The second classification is that of the APA (American Psychiatric Association) which since 1952 has published the DSM (Diagnostic and Statistical Manual of Mental Disorders).
While the DSM rains fierce criticism from the community of doctors and psychologists but also from strangers to the profession, little or nothing is said about the ICD. This is strange considering that the two diagnostic systems broadly converge with similar criteria for almost all the diseases listed. On the other hand, the codes are the same and even in the United States officially the ICD-10 criders are used to which the DSM has made the codes correspond even if not for all diseases, as the revisions of the two manuals are not always simultaneous. : that of the DSM changes faster.
What is the DSM
This is not the Italian Psychiatric Association (APA) Mental Health Department of Mental Health, but the Diagnostic and Statistical Manual of Mental Disorders, now in its 5th edition 11,12.
The function of the DSM as the ICD is simple and well known to all professionals: to define diseases and classify them to cure them. Giving a code to a morbid condition means ensuring that it can be traced by those who make statistics such as Istat, by those who reimburse hospitalization costs or other expenses related to the disease; it allows you to be recognized as sick days and even disability, which is impossible if you do not define what is illness. In Italy, for example, there are 13 DRGs that refer to the WHO classification system (WHO), the ICD.
It is mainly used by clinicians to orient themselves in diagnoses: in fact both manuals offer operational criteria to identify existing clinical pictures and then set an adequate therapy on the basis of this classification.
But it also serves researchers to carry out research aimed at well-defined clinical pictures. Indeed, originally the DSM was born from search criteria for research purposes and only secondarily did it have a great success with the public and spread in the specialist and non-specialist medical class. Here comes the main criticism that concerns us more closely by Thomas Insel director of the US NIMH who created a parallel classification system that uses different criteria and is mostly used for research.
Despite this, the DSM was also developed for clinical use and for this reason, starting with the 1980 DSM-III, it was set up in a deliberately atheoric way to try to be as objective as possible. In short, these were descriptive operational criteria that would have allowed clinicians from any part of the globe (or at least the United States) to make consistent diagnoses. In fact, reliability (reproducibility of the diagnosis) was the main problem felt at the time.
A very famous study of the 1960s between American and British psychiatrists had in fact highlighted the diagnostic difficulties existing in the international psychiatric community with similar diagnoses in only a minimal percentage of cases 14,15,16,17. Participants in the study were shown recorded interviews and had to make diagnoses based on the clinical picture presented by the subjects being analyzed. The result was disastrous even if minimally coherent within the two different groups (more diagnosis of schizophrenia in the American group versus diagnosis of affective disorder in the European group).
The need for shared diagnostic criteria became an important point on the agenda of the committees responsible for researching diagnostic criteria.
The turning point came with the 1980 DSM-III which completely broke away from previous diagnostic manuals and whose operational criteria approached those of the World Health Organization (WHO) classification. Despite the declaration of an atheoric manual, in reality there were many compromises such as the introduction of personality disorders in axis II which reflected the point of view of the psychoanalytic community that still had an important weight in the American (and international) academic world.
With the release of the DSM-IV, psychiatrists soon realized that despite an improvement in the replicability of the diagnosis and a homogenization of the diagnoses, validity was still far from being found.
This is the biggest problem the DSM-5 has faced. In fact, at the beginning of 2000, when the commission was formed, there was talk of a “paradigm shift” with great enthusiasm, thinking that by now the knowledge of diseases was advanced enough to allow diagnoses with criteria closer to science, as is the case for other branches of medicine. But soon the drafters of the new manual realized that the research progress was not at a point to allow the diagnostic approach to be revolutionized, much less the concept of disease had not changed and the old descriptive operational criteria were still being used.
Cui prodest the DSM
Conspiracy theory is not lacking in psychiatry and every move of the academic world is attributed an interest of the pharmaceutical companies. Allen Frances also makes these accusations of influences from pharmaceutical companies and there are also sites that have instituted petitions against the DSM-5 and calls from many sides not to follow this manual.
The news of the criticism of the director of the NIMH with the establishment of new research criteria (the Research Domain Criteria Project – RDoC) has rekindled the criticisms and fueled them. The news could be a bombshell since the NIMH deals with a large part of the studies conducted by US institutions and in which large amounts of money pass on which the funding of the studies themselves depend.
The detractors of this classification have jumped at the news as a demonstration of the scientific groundlessness of the well-known manual and continue to fire on psychiatry. In fact, the voices against psychiatry in general and the notion of mental illness never accepted by some are reactivated.
The reality would seem different. As reported on the pages of Scientific American in the scientific blog Brainwaves, “No One Is Abandoning the DSM, but It Is Almost Time to Transform It” 18. What emerges is a big misunderstanding: no one is abandoning the DSM even if everyone thinks it goes passed. The international scientific community is aware of the problems that have arisen with the previous revisions of the Manual with an increase in the diagnosis of some disorders, the lowering of the threshold of some diseases with the risk of treatment even when it is not strictly necessary. The problem is that these manuals must be used for what they are, tools for classifying and attributing codes, but it is not with them that we study psychopathology and become clinical every day. Perhaps this is what our American colleagues must learn, they should start over from psychopathology and not simplify the clinical approach to very complex diseases too easily. At the same time, the increase in diagnosis means greater attention from the community of psychiatrists to certain diseases that are still little known, such as ADHD in adults, another delicate aspect that is criticized by many, even if it is not negligible. An increase in the number of ADHD diagnoses in adults is likely to shrink other diagnosis groups such as mood and anxiety disorders. It is common experience of psychiatrists to find in the clinic generally very active adults who come to attention after a broken marriage, loss of work, and attention difficulties that you carefully investigate date back to childhood. These people diagnosed as depressed, anxious or bipolar could fall into other diagnostic categories, paving the way for more targeted therapies and more adequate care. It is possible that the growing interest in these aspects improves our knowledge and leads to new clinical and therapeutic developments.
In conclusion, as Craddock and Owen write, psychiatry is experiencing a moment of transition that will last as long as it will allow us to learn more about brain genetics to move from current descriptive criteria to clinical criteria 19.
Sources
1) http: // www .nimh.nih.gov / about / director / 2013 / transforming-diagnosis.shtml
2) http://alert.psychiatricnews.org/2013/05/david-kupfer-md-responds-to-criticism.html
3) http : //www.nytimes.com/2013/05/07/health/psychiatrys-new-guide-falls-short-experts-say.html
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4) http://www.guardian.co.uk/society / 2013 / may / 12 / medicine-dsm5-row-does-mental-illness-exist
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5) http://www.washingtonpost.com/lifestyle/style/the-bible-of-the-mind-turns-the-page/2013/05/12/17d8fc1c-b1b6-11e2-baf7-5bc2a9dc6f44_story.html
6 ) http://www.huffingtonpost.com/allen-frances/dsm-5-where-do-we-go-from_b_3281313.html
7) http://www.psych.org/annualmeeting
8) http: // www .neuropsychologie.fr / index.php
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9) Anais Ginori and Massimo Recalcati: The new DSM and the commercialization of mental disorders. La Repubblica, 8 May 2013.
10) http://www.humantrainer.com/attualita/dsm-v-passo-stampa-aumentano-polemiche.html
11) http://www.psychiatry.org/practice/dsm
12 ) https://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disorders
13) https://it.wikipedia.org/wiki/Diagnosis-related_group
14) Kramer M. Cross-national study of diagnosis of the mental disorders: origin of the problem. Am J Psychiatry, 1969; 10 suppl: 1-11.
15) Cooper JE, Kendell RE, Gurland BJ, Sartorius N, Farkas T. Cross-national study of diagnosis of the mental disorders: some results from the first comparative investigation. Am J Psychiatry, 1969; 10 suppl: 21-9.
16) Kendell RE, Cooper JE, Gourlay AJ, Copeland JR, Sharpe L, Gurland BJ. Diagnostic criteria of American and British psychiatrists. Arch Gen Psyhciatry, 1971; 25 (2): 123-30.
17) Kendel RE. Psychiatric diagnosis in Britain and the United States. Br J Psychiatry, 1975; Spec No 9: 453-61.
18) http://blogs.scientificamerican.com/brainwaves/2013/05/07/no-one-is-rejecting-the-dsm-but-it-is-almost-time-to-transform-it/
19) Craddock N, Owen MJ. Kraepelinian dichotomy – going going… but still not gone. Br J Psychiatry, 2010; 196 (2): 92-5. – http://bjp.rcpsych.org/content/196/2/92.full.pdf+html
