Bob – Page 5 – Integral Health Resources

March 20, 2014March 20, 2014

Substance-Related and Addictive Disorders in the DSM-5

Of all the changes from DSM-IV to DSM-5, I am most keenly interested in the reframing of substance-related disorders and the related inclusion of gambling disorder as an “addictive disorder.” I spent several years working on a chemical dependency unit in a psychiatric hospital, and my main role was providing psychoeducational groups to adolescent patients who were diagnosed with a substance-related disorder. I also accompanied the patients to Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings several times per week. One of the more challenging aspects of the job was that these inquisitive young patients often questioned me and other staff members about the many contradictions they perceived between AA’s philosophy/approach, the information packets about chemical dependency provided by the hospital, and their own life experiences related to substance use and abuse. For instance, they might say something like the following:

“I personally know several people who used drugs heavily for years and then quit or cut down on their own, without any treatment centers or twelve step groups. So, why is everybody here telling me I can’t stop getting high on my own, that I’m powerless over the ‘disease of addiction’?”

I found it difficult to integrate the various perspectives about substance use problems in a way that made clear sense to these young patients (and to myself as well!). DSM-IV focused on the distinction between substance abuse and substance dependence; the twelve steps focused on admitting one’s powerlessness over the spiritual disease of addiction; the National Institute on Drug Abuse (NIDA) described addiction as a chronic, relapsing brain disease; and our hospital treated substance-related disorders from a psychosocial perspective, focusing on group therapy, family therapy, and community support for our patients.

In the years leading up to the publication of DSM-5, I read with interest many media reports about the proposed changes to the substance-related disorders diagnoses. For instance, DSM-IV Task Force chair Allen Frances (2010) lamented that DSM-5 changes would lead to increased mislabeling of people with mild substance abuse problems as “addicts.” Ian Urbina (2012) published a widely read article in the New York Times which claimed that the DSM-5 would reduce the number of symptoms required for a diagnosis of drug/alcohol addiction, which could lead to many more people being inappropriately diagnosed as drug addicts. I was highly sympathetic to these critiques of the DSM-5 changes, that is until I read the DSM-5 chapter on Substance-Related and Addictive Disorders for myself. I discovered that many of the widely publicized critiques regarding this particular change in the DSM-5 were simply inaccurate, at least as they relate to the final published version of the manual. For example, while it’s true that substance use disorder in DSM-5 more or less combines the DSM-IV categories of substance abuse and substance dependence into a single disorder (i.e., substance use disorder), the new manual does not apply the word “addiction” to this class of disorders. The DSM-5 (2013) clearly states that the word addiction, while commonly used by both clinicians and laypersons around the world,

“is omitted from the official DSM-5 substance use disorder diagnostic terminology because of its uncertain definition and its potentially negative connotation” (p. 485).

Also, contrary to the often repeated charge that DSM-5’s general criteria for substance use disorders have been weakened by the combining of the previous categories of abuse and dependence, a strong case can be made that the new criteria have been strengthened:

“Whereas a diagnosis of substance abuse previously required only one symptom, mild substance use disorder in DSM-5 requires two to three symptoms from a list of 11” (American Psychiatric Association, 2013, para. 2).

Furthermore, the American Psychiatric Association (2013) makes the case that the previous DSM-IV category of “dependence” was problematic, as people often seemed to associate the concept of dependence with the concept of addiction, causing just the type of confusion I noted above when describing the young patients I worked with at the hospital.

At this early point in my knowledge of the new DSM-5 criteria, I am inclined to see the revised substance use disorder diagnoses — characterized by overarching criteria across substance classes and a severity continuum ranging from mild to severe — as a potentially useful advance in the conceptualization of substance-related disorders. I’m not sure, however, how I feel about the inclusion of gambling disorder in the new category of “addictive disorders.” While I understand the rationale behind this inclusion (i.e., the available research associating disordered gambling behavior with reward systems in the brain that are also linked to disordered substance use), I’m concerned that this linking of substance-related and nonsubstance-related disorders requires a far more extensive re-visioning of the concept of “addictive disorder” than is provided in DSM-5. Assuming that future research establishes and confirms the requisite connections between other “behavioral addictions” (e.g., those related to excessive internet use, sex, shopping, exercise, etc.) and specific reward systems in the brain, another major revision of this DSM chapter will likely be necessary, and that hard-to-define term “addiction” might become even more difficult to understand and talk about!

References
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, D.C.: Author.

American Psychiatric Association. (2013). Substance-related and addictive disorders (fact sheet). Retrieved October 30, 2013 from http://www.dsm5.org/Documents/Substance%20Use%20Disorder%20Fact%20Sheet.pdf

Frances, A. (2010, March 30). DSM5 “Addiction” Swallows Substance Abuse.
Psychiatric Times. Retrieved October 30, 2013 from
http://www.psychiatrictimes.com/articles/dsm5-addiction-swallows-substance-abuse

Urbina, I. (2012, May 12). Addiction diagnoses may rise under guideline changes. New
York Times. Retrieved October 30, 2013 from
http://www.nytimes.com/2012/05/12/us/dsm-revisions-may-sharply-increase-addiction-diagnoses.html

February 9, 2014February 9, 2014

Prisoners, Mental Health, and Mindfulness

India, 42, suffers from manic depression and post-traumatic stress disorder. She has spent almost all of her adult life in jails and prisons. [John Gress for The New York Times]

I was catching up on my interweb reading list this morning and was struck by two pieces about prisoners and mental health. The first was an op-ed piece by New York Times columnist Nicholas Kristof called Inside a Mental Hospital Called Jail. Kristof cites a 2006 Justice Department study that claims that more than half of prisoners in the US have a mental health problem, with females in particular showing diagnosable mental disorders in an astonishing 75% of the inmate population. It’s just staggering to contemplate how many human beings are presently languishing in prisons mostly due to mental health problems (including substance abuse issues) that are bound to get far worse in prison environments that are not committed to treatment and rehabilitation.

On the bright side, I was greatly impressed with the work of former prisoner Fleet Maull of the Prison Mindfulness Institute. Maull began teaching mindfulness to prisoners while he was serving a 14-year sentence for drug trafficking. In the powerful short film below, Maull points out that often times what lands people in prison (and frequently brings them back) is a lack of good problem-solving and communication skills. By teaching prisoners some foundational social-emotional self-regulation skills through mindfulness techniques, Maull is not only giving prisoners some tools to help them successfully adapt to life behind bars, but he’s also preparing them to succeed in life outside of prison, if they are fortunate enough to have that opportunity.

Path of Freedom from Go Project Films on Vimeo.

January 28, 2014

McMindfulness: I’m Lovin’ it!

I started my first psychology graduate program in 1994, and I never would have guessed then that “mindfulness” would be on the cover of Time Magazine twenty years into the future. Of course, I also would have never guessed that very few people would actually read magazines (including Time) in the year 2014. That first graduate program was focused on East/West Psychology, and I had a devil of a time explaining what that meant to just about everyone outside the California Institute of Integral Studies . Today, I just tell people “We studied mindfulness meditation and stuff like that” and most people seem to get it. Heck, these days people actually approve of the fact that I spent money on such a degree! I have to admit though, it’s pretty weird to see how crazy-big this whole mindfulness thing has gotten in the past ten years or so. There’s a small part of me that misses feeling like I was in some select group of “pioneers” who were into mindfulness before it was cool, as if this ancient practice were some obscure indie rock band that only played small clubs back in the 90’s.

Today I test drove a new app called Stop, Breathe & Think that promises to “guide people of all ages and backgrounds through meditations for mindfulness and compassion.” I was looking for tools that might be useful in explaining mindfulness to the elementary school students that I’m working with as part of my present-day graduate practicum. I was looking for something that makes mindfulness seem cool, a fact that can easily be lost on kids raised in this age where shiny rectangles lord over our attention spans 24/7. I’m impressed with the app so far. It’s a good introduction to mindfulness, which is really all you can offer in the context of an elementary school guidance program.

Mindful Schools is another interesting program that both my supervisor (the licensed counselor at the school) and I are impressed with as a way to introduce mindful practices into the school setting. Here’s an introductory video:

I’ve noticed that there’s a bit of a backlash lately against the mainstreaming of mindfulness, and I’m not totally unsympathetic to the fact that “McMindfulness” versions of deep and complex teachings can have their drawbacks. Still, McMindfulness is a problem that strikes me as both inevitable and quite manageable. However basic a particular meditation technique might be, I can’t help but be thrilled that, twenty years after being introduced to the practice myself, I can walk into an elementary school and watch a licensed counselor teach kids how to meditate, and nobody thinks he’s out of his mind!

January 8, 2014

David’s Shadow: Reflections on a 9-year-old’s ADHD Diagnosis

A while back I was employed as a teacher’s aide at a local elementary school. I spent each morning (from 7:45am – 11:25am) Monday through Friday working in a third grade classroom, assisting the teacher with all manner of classroom activities. My primary role, however, was to monitor and manage students’ behavior, particularly the behavior of a student named David. (All names and background information have been altered to protect confidentiality.)

On my first day of work the teacher informed me right away that David was the “problem child” of the class. School had been in session for two weeks before I started working at the school, during which time David had reportedly exhibited some disruptive behaviors. The teacher described David as a restless, impulsive child who had difficulty staying focused and on task. At nine years old, David had not yet been diagnosed with any psychiatric disorders or learning disabilities. In fact, by the teacher’s account, David was “bright” in terms of academic ability. She attributed his behavior issues to his family upbringing. “His father is a gang member,” she told me on my first day, “and his mother has a bunch of tattoos to go along with her bad attitude. They let David get away with murder at home.” My own initial impressions of David were quite different from those expressed by his teacher. I liked him right away, especially his sense of humor, which had a wry, subversive quality to it that I admired. David did indeed seem to be very bright and, when he was engaged and interested in classroom activities, he participated in discussions appropriately and made insightful contributions. He did, however, seem bored much of the time, and he would frequently express his lack of interest by making barely audible comments, like saying “Bo-ring” under his breath, or intentionally giving a silly answer to one of his teacher’s questions. David also seemed fidgety and restless much of the time while the teacher was instructing the whole class. The teacher redirected him quite frequently for behaviors such as tapping his pencil, playing with objects like erasers and paperclips, and squirming around in his seat.

A few days into my new job, the teacher instructed me to be “David’s shadow,” meaning I should focus attention on David whenever I wasn’t otherwise engaged with other students or duties. This role gave me many opportunities to observe and interact with David throughout each morning over the course of the semester. David was soon placed on a behavioral contract, which in part meant that he was to receive star-shaped stickers from school staff for each block of time he was able to show appropriate behaviors. David seemed to respond well during the periods of the morning when he received one-on-one attention (i.e., from me), but he was reportedly more prone to inappropriate behaviors during the afternoon, after I had left for the day and the teacher was in the classroom without the support of an assistant.

Over the course of the semester, I not only had the opportunity to work with David each morning during routine school days, but I also accompanied David on a field trip to see a play, I sat with him during “movie day” as we watched the animated film Monster House, I played tag with him and his friends during recess on one occasion, and I sat down with him and his mother during a parent-teacher conference meeting. In general, David seemed to be a happy child who was well liked by his peers. His sense of humor seemed to endear him to his fellow students, and to many school staff as well. In the time I spent with him, he never mentioned any problems at home or problems with peers at school. David and I mostly shared moments of humor, like when he would show me a silly picture he had drawn, or when he’d recall the fun we had playing tag the day I joined the class for recess time. David would also frequently ask me for help with his schoolwork, especially spelling. For the most part, David responded respectfully and without protest whenever he was redirected (by either the teacher or myself) for inappropriate behaviors, and he normally accepted disciplinary measures (e.g., having to write “behavior reflections” assignments, having to sit at a table by himself, or losing “privilege points”) with only a minor show of disappointment. When I would talk with him about why he was getting in trouble, David would usually say something to the effect of “I’m bored” or “This stuff we’re doing is boring.”

I noticed that David especially liked to use the technology in the classroom, which included computers, an iPad, and a large “smart board” the teacher allowed the students to use occasionally. When classroom instruction was centered around technology, David was far more likely to be engaged and on task, but he also got in trouble quite often for using the technology out of turn or at inappropriate times. He would frequently be dishonest in an effort to maximize his time using the technology, and then as a consequence his privileges became more and more restricted. It became somewhat of a vicious circle David was getting caught in, as his behavior became more disruptive the more he was prevented from engaging in the technology-based activities that he enjoyed.

At the parent-teacher conference meeting, David’s mother agreed with the teacher that something more needed to be done about David’s impulsive and disruptive behaviors, which apparently were also problematic at home. A plan was set in motion to get David tested for attention deficit hyperactivity disorder (ADHD), and within a few weeks David was (according to his teacher) taking medication for the condition. I was surprised and saddened to learn that David had been placed on ADHD meds. I recognize that I am neither a doctor nor a school psychologist, and because I was not part of the treatment team charged with making decisions on David’s behalf, I was never made aware of all the information that may have been pertinent to David’s situation. My response is a personal one, and my opinions are presented here simply as part of my own reflection process.

My sadness had to do with my strong sense, based on my experiences with David, that his problematic behaviors were not an expression of pathology or a disorder of any kind, but rather they were simply David’s way of expressing his general lack of interest in and engagement with the methods of curriculum delivery most commonly utilized in the classroom. I sat next to David the day the class went on a field trip to watch a play. The play was very humorous, and David was well behaved and thoroughly engaged throughout the performance. He seemed to be “in his element,” as he did on the occasions when he was enjoying recess on the playground or engaging with the classroom technology. David’s abundant energy and active sense of humor—two of his most prominent qualities—were not particularly engaged during periods of the school day when he was required to sit passively in his chair and stay relatively silent. Compounding David’s problems, he would often lose his recess privileges (and therefore his opportunity to run around on the playground) as a consequence for his misbehaving, thus setting him up for more difficulties later in the day as he struggled to regulate his energy level.

David’s situation reminded me of an article we read in our School Counseling class that same semester about the possible trend among certain physicians to prescribe stimulants to struggling students, particularly students from lower income families, whether or not those students meet the criteria for ADHD (Schwarz, 2012). More than one of the doctors mentioned in the article lamented that we as a society have been unwilling to invest the time and funds necessary to optimize the success of struggling, lower income children, and therefore we are putting increased pressure on healthcare and other professionals to use the most cost-effective approach at their disposal—that of medicating children. As one doctor chillingly put it: “We’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.” (Schwarz, 2012, para. 3). Comedian Stephen Colbert (2012) satirically referred to this pharmaceuticals-first approach as “meducation,” a method of behavior modification that I find particularly disturbing, especially now that (in my opinion) I have directly seen it applied to a child.

Many people disagree about what constitutes appropriate psychiatric diagnosis and/or use of psychotropic medication with children, and this is an issue that caused me a great deal of concern in my experience working with David. Soon after David started taking medication, he started complaining of stomach pain, and he seemed to lack his usual appetite and ebullience. He slumped in his chair looking ill while the class watched Monster House on “movie day.” The class had brought treats and snacks to enjoy with the film, but David uncharacteristically declined to have anything to eat. The teacher told me afterwards, “The doctor raised his med levels yesterday. He’s probably taking a little too much.” As we discussed David’s progress in school, the teacher made it clear that both she and David’s parents had noticed a remarkable improvement in his behavior since he started on his medication. While it may have been true that David’s behaviors were not as disruptive after he was put on medication, I couldn’t help feeling that these gains came at too great a cost. If only David and students like him could receive a bit more one-on-one attention and individualized instruction, perhaps improvements in behavior could be realized without having to risk the possible side effects of pharmaceuticals.

I thoroughly enjoyed my experience working with David and the other students in his third grade classroom. Children at this developmental level are particularly open to learning, and their boundless energy and enthusiasm make it fun to engage with them. It was sobering, however, to see first-hand the various social issues—such as poverty, racial bias, and suboptimal parental supervision—that affect many of the children school-wide. David seemed to thrive when he was given the increased attention that I was able to provide during the few hours each school day I was with him in the classroom. I have no doubt that he could continue to thrive and maximize both his developmental and academic potential if only the school environment could adapt to his needs by providing more staff support for him throughout the school day.

Of course, extra support costs extra money that is not available to many schools, and I am sympathetic to David’s parents and his teacher, who likely were doing their best under challenging circumstances to help David succeed in school. Although I was disheartened by the decision to modify David’s behavior by modifying his brain chemistry with psychotropic medications, I am still hopeful that his fiery spirit will burn brightly as he finds his way through this difficult process.

References
Colbert, S. (2012). Colbert Nation website. Retrieved from http://www.colbertnation.com/the-colbert-report-videos/420013/october-10-2012/the-word—meducation

Schwarz, A. (2012, October 9). Attention Disorder or Not, Pills to Help in School. The New York Times. Retrieved from http://www.nytimes.com/2012/10/09/health/attention-disorder-or-not-children-prescribed-pills-to-help-in-school.html

December 29, 2013

Carl Rogers on Empathy

One of last semester’s highlights was stumbling upon this gem of a lecture from the inimitable Carl Rogers. Rogers begins the 1974 talk by reflecting on the educational value of reviewing films of himself conducting person-centered counseling with clients. For my part, I was struggling mightily to find the value in reviewing videos of my own counseling sessions throughout the semester. In fact, I downright hated the process. Rather than obsess over everything I could have or should have done in a session already past, what I most wanted to do was observe a true master counselor at work. And so I watched as much of Carl Rogers as I could find online, and it helped to get me through. Enjoy!

November 23, 2013December 29, 2013

Shifting Paradigms in Psychiatry: A Dialogue between Dr. Allen Frances & Dr. Lucy Johnstone

It’s refreshing to witness a dialogue grounded in civility and mutual respect, as was presented in Dr. Allen Frances’s blog a few weeks ago. Much of the current debate regarding the state of modern psychiatric diagnosis and treatment comes down to the relative emphasis given to the biological vs. the psychosocial dimensions of human experience and behavior. Dr. Lucy Johnstone, a clinical psychologist in the United Kingdom, suggested to Dr. Frances that the biomedical model of mental illness (i.e., the assumption that mental distress is mainly caused by biological dysfunctions in the brain and body) has “comprehensively failed” and should be replaced by an alternative view:

The alternative view can be summarized as the belief that people break down for reasons in their lives and relationships—loss, trauma, abuse, poverty, discrimination, domestic violence and so on. These experiences are bound to be reflected in the brain and body in some way, but the evidence suggests that even the most extreme forms of mental distress can be understood in the context of life circumstances and the sense that people have made of them; in other words, by asking not ‘What is wrong with you?’ but ‘What has happened to you?’

Frances, while agreeing with Johnstone that the biomedical model is incomplete and has been oversold–to the detriment of patients–, is concerned that Johnstone’s articulation of an alternative view represents a “psychosocial reductionism” that may prove to be just as incomplete and harmful as the biomedical reductionism it seeks to replace. Frances makes the case for a more balanced approach:

The integrated bio/psycho/social model has a long tradition and remains the best guide to clinical practice. It has always been threatened by reductionisms that would privilege one component over the others–but this interacting tripod of bio/psycho/social approaches is unstable and incomplete without the firm support of all three of its legs. In my view, it is equally mistaken to call for a premature ‘paradigm shift’ tilting toward biology (as was suggested by DSM and NIMH) or a ‘paradigm shift’ tilting toward the psychosocial (as was suggested by the DCP [and Johnstone]). An integrated bio/psycho/social model is essential to understanding each patient and also to unite the mental health professions.

Interesting stuff. I’m just glad to see that this debate is getting some long overdue attention, and I’m hopeful that thoughtful individuals like Johnstone and Frances can make a real difference in pushing the debate (and the field of mental health) forward.

For more see: Does It Make Sense To Scrap Psychiatric Diagnosis?

October 19, 2013December 29, 2013

Diving in to DSM-5

Yes, this photo is of my personal copy of the DSM-5, as it looked during my open-book midterm exam this past week. It’s been a long while since I’ve found the time to post here, as graduate school has been particularly demanding this semester. I was thinking though — Why not better integrate my grad school experience with this blog? I’ve featured several others’ perspectives on the DSM-5, so why not include my own as I dive into the manual throughout my Diagnosis & Treatment Planning class? Without further ado, my reflections on the introductory section:

The introductory chapter to the DSM-5 was helpful in providing some historical and scientific context for the manual. I appreciated that both the virtues and limitations of using DSM criteria were discussed, and that the APA envisions the DSM as a “living document” that will adapt to future research developments. However, I was struck by the fact a biomedical model of mental disorders (i.e., understanding mental disorders in terms of disease, symptoms, treatment, etc.) was presented implicitly, as if the validity of such an approach is beyond doubt. Given that the APA is a group of psychiatrists, i.e., medical doctors, it was not surprising to see medical language and metaphors (such as “eventual cures,” “disease origins,” “course of illness,” “biomarkers,” and “shared neural substrate”) sprinkled throughout the introductory remarks. As someone with a humanistic, biopsychosocial orientation to health (mental, physical, and societal), I am not comfortable with the DSM’s implicit view of psychological distress as ultimately a matter of “underlying pathophysiological processes” that will someday be understood by medical science. Although the complexities and psychosocial dimensions of human experience and behavior are acknowledged as influential factors affecting symptom expression and disease progression, the underlying biomedical view is taken for granted. In describing the DSM-5 as a “living document,” the authors acknowledge a certain kind of openness to change and revision, but they mention only the medical sciences of neurobiology, genetics, and epidemiology as potential sources of new knowledge. As with previous revisions of the DSM, the DSM-5 Task Force acknowledges the flaws of the previous versions of the manual and offers improvements, but I can’t help but wonder if the limitations of conventional psychiatric diagnosis and treatment are to be found through a more thorough examination of the fundamental philosophical assumptions underlying the field. I will be pondering this throughout the class.

I was surprised that the term “mental disorder” was not defined until page 20, because it seems to me that the entire prior discussion was dependent upon that definition. I found it interesting to note that expectable responses to stressors as well as socially deviant behaviors resulting from conflicts between individuals and society were defined as NOT being mental disorders. The authors also stressed the need for expert clinical judgment in differentiating between diagnostic criteria and “normal life variation” and “transient responses to stress,” and I found myself wondering how such a line between normal and pathological could ever be defined with any degree of scientific certainty. While the authors acknowledge these and other thorny issues inherent in psychiatry, they maintain that their approach is the best available system for supporting clinicians and researchers in the field of mental health. I have my doubts. From what I understand from reading Section I of the DSM-5 along with various outside critiques, the manual was not subject to a truly “independent” review process, as the Scientific Review Committee (SRC) given the task of review was established by the DSM-5 Task Force itself. Also, the manual purports to have avoided conflict of interest by requiring income disclosure of its 28 task force members, neglecting to mention what the majority of members actually disclosed—i.e., their direct financial ties to the pharmaceutical industry.

One thing I was unclear about is how the DSM-5 presumes to integrate the categorical diagnostic system of previous editions (which it criticizes as being untenable and incongruent with clinical realities) with a new “dimensional” approach to diagnosis that transcends categories. The Cross-Cutting Symptom Measure (an “emerging” assessment measure described in Section 3 of the manual) seems to be an interesting and useful way to integrate a dimensional analysis into the diagnostic and treatment process. I suppose it will eventually become clearer to me, as I read through the various diagnostic criteria, just how to integrate the dimensional and categorical perspectives.

May 12, 2013December 29, 2013

Meet the new boss, same as the old boss: The NIMH rejects DSM categories, but continues to give short shrift to psychosocial perspectives

The National Institute of Mental Health will reportedly discourage the use of DSM categories for its future research projects. NIMH Director Thomas Insel is promoting a new approach, the Research Domain Criteria (RDoC), which is based on three guiding principles: 1) Pathology is conceived in terms of dimensions ranging from normal to abnormal; 2) Classification of disorders will be generated from basic behavioral neuroscience, not current DSM categories; 3) Multiple units of analysis (i.e. physiological activity, behavior, self-reports of symptoms) will be used in defining constructs for study. In a recent article by Maia Szalavitz, Insel is quoted as saying:

I look at the data and I’m concerned. I don’t see a reduction in the rate of suicide or prevalence or mental illness or any measure of morbidity. I see it in other areas of medicine and I don’t see it for mental illness.

As I understand it, the basic idea behind RDoC is that researchers will likely be more successful in understanding the neurological and genetic underpinnings of psychiatric disorders if they focus on specific symptoms, which may occur across multiple disorders, rather than continue to focus on disease categories based on complex groupings of various symptoms. This makes sense to me as a better way to approach the biological dimensions of mental health, but it also implies that the NIMH, like the American Psychiatric Association, is content to downplay the subjective, interpersonal, and sociocultural dimensions of mental health and distress, at least when it comes to research funding. As Benjamin Wachs puts it:

The NIMH isn’t offering a real alternative to the DSM: rather, they’re doubling down on the fallacy that the DSM was pursuing in the first place. That the mind is best understood as a computer, and when your computer breaks you don’t talk to it or ask it how it feels. In fact, you don’t even let the computer decide whether it’s broken or not. If it’s not behaving according to spec, you get it fixed.

DSM-IV Chair Allen Frances said the following his recent analysis of the topic:

APA and NIMH are both on the sidelines, doing nothing to help restore humane and effective care for those who most need it. DSM-5 introduces frivolous new diagnosis that will distract attention and resources from the real psychiatric problems currently being neglected. NIMH has turned itself almost exclusively into a high power brain research institute that feels almost no responsibility for how patients are treated or mistreated in the here and now.

There seems to be two major viewpoints in the mental health field these days. The first, typified by highly influential organizations like the APA and NIMH, sees mental health as primarily a matter of brain functioning. Lip service is often paid to “cultural factors,” but the subjective, intersubjective, and sociocultural dimensions of humanity are given short shrift in terms of emphasis and resource allocation. The second major trend in mental health is the integrative or integral view, which insists that every dimension of humanity must be fully taken into account in all mental health theory, research and practice. The NIMH’s new research direction will hopefully bear fruit, but it will miss the big picture if the narrow focus on neuroscience is not placed within a broader biopsychosocial context.

May 10, 2013May 10, 2013

Allen Frances vs. DSM-5

The new version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is about to drop, and those of us in the mental health field will have to respond and/or adapt to the changes in some way. In my graduate program, the most prevalent response seems to be annoyance at having to learn a new system. Strangely, I’ve heard very little buzz among students and faculty regarding the many critiques of the new manual that have been sprouting up daily across various media outlets over the past year or so. It’s as if students are resigned to accepting whatever dictates come down from the American Psychiatric Association because, well, “that’s the way it is” and “what can we do about it anyway?” I’m not always the most socially engaged student, so perhaps there’s more engaged critical discussion going on than I’m aware of. I hope so.

Foremost among DSM-5 critics is Allen Frances, the chair of the task force that produced the version of the manual, DSM-IV, that has been in use since 1994. Frances came out of retirement out of a concern that the proposed changes in DSM-5 would lead to a dangerous level of diagnostic inflation, and he’s been blogging, writing articles and books, and giving talks all over the world encouraging people to seriously question the DSM-5’s safety and legitimacy. In a recent opinion piece for New Scientist, Frances summarizes his scathing critique:

In my opinion, the DSM-5 process has been secretive, closed and sloppy – with confidentiality restraints, constantly missed deadlines, botched field testing, the cancellation of an important quality control step, and a rush to publication. A petition for independent scientific review endorsed by 56 mental health organizations was ignored. There is no reason to believe that DSM-5 is safe or scientifically sound.

A more detailed critique (and a mea culpa for the mistakes in DSM-IV) is explored in the following talk, which I find to be very impressive and persuasive:

Psychiatrist and author, Allen J. Frances, believes that mental illnesses are being over-diagnosed. In his lecture, Diagnostic Inflation: Does Everyone Have a Mental Illness?, Dr. Frances outlines why he thinks the DSM-V will lead to millions of people being mislabeled with mental disorders. His lecture was part of Mental Health Matters, an initiative of TVO in association with the Centre for Addiction and Mental Health.

Of course, Frances is not alone in criticizing the DSM-5. See my twitter feed for the most credible and thoughtful (in my view) critiques being published on the web.

April 25, 2013April 25, 2013

Psychiatric diagnostic system challenged by genetic research

Vaughan Bell (of the terrific blog, Mind Hacks) has posted a couple of fascinating articles highlighting recent evidence from genetics that is challenging the field of psychiatry to rethink how it views diagnosis. In a post published in The Guardian, Bell frames psychiatry’s current diagnostic dilemma as follows:

[Do] different diagnoses such as schizophrenia, bipolar or depression represent distinct disorders that have specific causes or [are these] just convenient and perhaps improvised ways of dividing up human distress for the purposes of treatment?

Bells reminds us that the diagnosis debate is typically framed in terms of two opposing models, a medical model that views psychiatric disorders in terms of diagnosis, medication and biomedical science, and a social model that stresses individual experience, psychotherapy and social interventions. This debate has been heated and politicized, and now it may be further complicated (or elucidated) by evidence from medical genetics that suggests that psychiatric diagnoses do not, in fact, represent distinct disorders, but rather they represent a variety of possible problematic outcomes each stemming from a similar genetic starting point that has been uniquely shaped by an individual’s life experiences.

Bell interviewed Dr. Michael Owen, a psychiatrist and researcher from Cardiff University’s School of Medicine who had studied genetic research related to psychiatric diagnosis in depth. Owen concludes that “It is no longer tenable to regard these as discrete disorders, or sets of disorders, with specific causes, symptoms and consequences.” Interviewing Owen for a follow-up article, Bell explores the possibility of an expanded neurodevelopmental theory suggesting the likelihood that “genetics determines how sensitive we are to life events as the brain grows and develops.”

Dr. Owen and his colleagues gathered and analyzed a great deal of evidence showing that certain genetic differences raise the chances of developing a whole range of psychiatric problems – from epilepsy to schizophrenia to ADHD – rather than these differences being linked to a specific psychiatric disorder. Asked to expound on what the current categories of psychiatry diagnosis (i.e. per the DSM) represent, Owen said:

They are broad groupings of patients based upon the clinical presentation, especially the most prominent symptoms and other factors such as age at onset, and course of illness. In other words they describe syndromes (clinically recognizable features that tend to occur together) rather than distinct diseases. They are clinically useful in so far as they group patients in regard to potential treatments and likely outcome. The problem is that many doctors and scientists have come to assume that they do in fact represent distinct diseases with separate causes and distinct mechanisms. In fact the evidence, not just from molecular genetics, suggests that there is no clear demarcation between diagnostic categories in symptoms or causes (genetic or environmental).

Interesting stuff! I’ll keep my ear to the ground for any new developments.