Diagnosis and a clear-cut nosology are vital for treatment, but overdiagnosing leads to a needless waste of resources and insurance reimbursement — both inexcusable IMHO. But with each iteration of The American Psychiatric Association’s DSM (Diagnostic & Statistical Manual of Mental Disorders), aka ‘the Bible’ of diagnosis, we find ever more disorders added or under consideration.
Look in the back of the book, and you’ll find those for future consideration, many of them cultural in nature. This point indicates that the prior diagnoses in the earlier editions of the manual could too heavily load on American culture.
An interesting, unacceptable previously diagnosed in the “to be considered” category was nightmare deaths of Laotian men. How did they diagnose it? Perhaps some form of psychosis? In the Philippines, it is known as bangungut. And it has also been categorized as Oriental nightmare death syndrome. Is it a psychiatric disorder or a cultural belief?
The team that worked on the latest iteration of the DSM indicated that “more than 200 subject matter experts” worked on the book, including ethnocultural and racial concepts.
Questions arise regarding the reason these cultural and racial elements were missing in prior editions and whether they stigmatized patients in the past. The number of experts does not strengthen the book’s content, just as the number of subjects in a protocol doesn’t necessarily increase its validity. It’s illusory. Numbers alone are not magical.
Are there many as-yet-undiagnosed mental illnesses waiting to be discovered and treated, or is there too fervent an eagerness to find the obscure and plump-up, already burgeoning manual? One has to wonder at the expense of sounding skeptical of both motives and medicine.
Over the past few decades, psychiatry has undergone a seismic change from analytic practice to biological concerns and research. In the DSM, the specialization tends more toward psychology than biological medicine. We know thousands of healthcare personnel use the tome without medical degrees.
I recall working in psychiatry research where we saw psychiatry residents who were disillusioned because they thought they would learn how to practice psychotherapy, not look at blood draws or medication side effects. The department began to select only those interested in biological psychiatry, and any who found this unacceptable had to find substitute residency programs. To my mind, it seemed there should be a melding of the DSM and the then-current Physicians’ Desk Reference, now known as the Prescribers Digital Reference.
Perusing the DSM will quickly reveal no biological diagnostic indicators for a psychiatric diagnosis other than behavioral symptoms. There are no required blood tests, no serologic tests, and no imaging (even for Alzheimer’s). So, is this medicine in the true sense or psychology?
One point that also contributes to the existence of this manual is that insurance companies wished to have something on which to rely for reimbursement. And reimbursement may play a role in giving patients diagnoses other than the evident one. In family therapy, the mother may be the IP (identified patient). Should she be placed in that role, or is the diagnosis being skewed for the insurance?
There were two categories of physicians in a psychiatric hospital where I once worked: medical doctors and psychiatrists. All psychiatrists are medical doctors, so why the dichotomy? I never did get an answer because I don’t believe anyone knew how it came to be.
And when medical doctors in the hospital noted a sharp uptick in diabetes in patients on the units, there was little to no discussion with psychiatrists about psychotropics playing a role in its incidence. It did have a role they later discovered. Some patients on specific drugs gained an inordinate amount of weight without an intake of additional calories.
One voice calling out against what he indicates is the “medicalization” of normal life is the eminent psychiatrist, Dr. Allen Frances, once the chairman of the committee to establish the DSM in its overall position of power of diagnosis. His concern regarding the current issues resulted in writing “Saving Normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life.”
The book was a shot over the bow of those promoting the DSM as the ultimate text for diagnosis. But this isn’t the only area where Dr. Frances has expressed his concern because he believes that the diagnosis of ADHD in kids is far too common.
We’ve seen the prior wave of diagnosis of children with bipolar disorder begun by Dr. Joseph Biederman, a well-known child psychiatrist. “Dr. Biederman’s work helped to fuel a fortyfold increase from 1994 to 2003 in the diagnosis of pediatric bipolar disorder and a rapid rise in the use of powerful, risky and expensive antipsychotic medicines in children.” Would most of us question, without a medical degree, the use of powerful drugs that act on a child’s developing brain?
I wonder what Dr. Frances thinks about the latest diagnosis of Prolonged Grief Disorder (PGD) added to the current edition known as DSM5-TR. The new addition is described as “the bereaved individual may experience intense longings for the deceased or preoccupation with thoughts of the deceased, or in children and adolescents, with the circumstances around the death. These grief reactions occur most of the day, nearly every day for at least a month. The individual experiences clinically significant distress or impairment in social, occupational, or other important areas of functioning.”
The concern among some healthcare professionals is that this new inclusion will be the tipping point for pharmaceutical interventions in a process that should be permitted its normal action. One research project for grieving consisted of a specific 16-week protocol with an antidepressant. The researchers believe that the new PGD disorder applies to about 4% of the population, but the pandemic may have increased the numbers.
While mental health professionals may wish to see PGD as treatable with medications for depression and anxiety and psychotherapy, there is agreement that little is known about the biology of grief. The missing pieces in the puzzle would seem to present a major impediment to effective care of those engaged in prolonged grieving. Where research exists, it has found a formidable negative connection with the immune system.
Additional protocols noted the increased mortality of spouses after the death of their spouse and the relationship between depression and cardiovascular disease. Undoubtedly, grief includes degrees of depression which can be long-term in nature. It affects an individual’s ability to function normally and may not wane sufficiently without intervention, but which persons need the intervention and for how long still requires investigation. Most will see grief gradually lessen over a six-month period without intervention, but others may take one to four years. The question is one of serious impairment in daily life.
Besides adding a new diagnostic category, there needs to be a proviso about combining medication with psychotherapy, not simply medication alone. The reverse is also true; psychotherapy without medication where it may be indicated.