Reflections on attention, self-knowledge, and the mental health profession.
In this episode of the Integral Health Resources Podcast, I discuss the new depression screening guidelines proposed by the The US Preventive Services Task Force, the response to these guidelines by Allen Frances, and the perils of podcast procrastination.
Related articles:
(Debate between Karina Davidson and Allen Frances)
In this episode of the Integral Health Resources Podcast, I review an excellent article by Allen Frances in which he excoriates us all for turning a blind eye to those in our society who need mental health services the most.
Here is the article that was referenced in this discussion:
What Drives Our Dumb and Disorganized Mental Health Policies? by Allen Frances
In this –the inaugural episode of the Integral Health Resources Podcast– I flounder about trying to figure out what on earth I’m doing. Topics include:
Summary:
I blogged about Insel’s new agenda for psychiatry a couple of years ago, HERE.
Here are some other media resources that may be helpful/relevant to this discussion:
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
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.
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.