The DSM and defining mental illness

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association and contains the most authoritative definitions of mental illnesses. The current version – the DSM-IV – was released in 1994. Now, work is ongoing on a fifth edition.

To me, it seems like ‘mental illness’ often describes a situation in which a person manifests a normal part of psychology to an excessive extent. For instance, it is perfectly normal and probably even essential for people to feel things like guilt, shame, and anxiety. Any of these felt to an extreme extent, whether that means extremely strongly or weakly, could form the basis for a mental illness.

There is a danger, perhaps, in being too quick to say that someone is ill, when they simply manifest a normal tendency to an unusual degree. Doing so might make them feel stigmatize and lead to unnecessary medical interventions. It also risks making people feel less responsible for their choices and actins, since they can be ascribed to a medical condition rather than to the free expression of their will. At the same time, increased awareness of mental illness is probably an important thing for society to develop. My sense is that most people do not have a great understanding of the character of mental illnesses, and that society is generally poorly set up to assist people suffering from them.

Author: Milan

In the spring of 2005, I graduated from the University of British Columbia with a degree in International Relations and a general focus in the area of environmental politics. In the fall of 2005, I began reading for an M.Phil in IR at Wadham College, Oxford. Outside school, I am very interested in photography, writing, and the outdoors. I am writing this blog to keep in touch with friends and family around the world, provide a more personal view of graduate student life in Oxford, and pass on some lessons I've learned here.

13 thoughts on “The DSM and defining mental illness”

  1. There is a danger, perhaps, in being too quick to say that someone is ill, when they simply manifest a normal tendency to an unusual degree.

    I think you’ve discovered why behavioral drugs are generally over prescribed. I’m all for pharmaceutical intervention when there is a need, and I think anti-depressants, for instance, work well for some people for some things. But to get a prescription for one is pretty easy, and in many instances cognitive behavioral therapy is much more effective, long lasting, and without side effects.

  2. You are right when you say that we do not understand much about mental illness and we are even less good at treating it. I once heard a schizophrenic person describe his mental state as a roller-coaster that does not stop after a few minutes, but rather accelerates until he is overwhelmed by anxiety and loss of control. Many bi-polar patients enjoy the sense of loss of control and hate the drugs that take away their feelings and “self.” Mental illness has a chemical component too and the degree varies from person to person. Most “normal” individuals have moments and even periods during which they are not any different from a person who suffers from mental illness. When it comes to treatment, it appears that society has not assigned it a very high priority to fund enough research and more importantly, to find humane ways to stand by the people whose lives are shattered by mental illness.

  3. “I am not being sarcastic here—or at least not entirely. In fact, I’ve reread both Tom Sawyer and The Adventures of Huckleberry Finn several times in recent years, precisely because Twain draws such fascinating portraits of children whose behavior is familiar, even if we now describe it differently. As a mother of boys, I find this weirdly reassuring: Although ADHD and ODD are often dismissed as recently “invented” disorders, they describe personality types and traits that have always existed. A certain kind of boy has always had trouble paying attention in school. A certain kind of boy has always picked fights with friends, gone smoking in the woods, and floated down the river on rafts.

    In previous eras, such behavior was just as problematic for adults as it is today. Poor old Aunt Polly—how many times does she “fall to crying and wringing her hands”? In order to cope with Tom, she seeks names for his disorder—he is “full of the Old Scratch,” meaning the devil—and searches for ways to control him (“Spare the rod and spile the child,” she tells herself).

    But if the children and the parents are familiar, the society surrounding them is not. In fact, Tom Sawyer turns out fine in the end. In 19th-century Missouri, there were still many opportunities for impulsive kids who were bored and fidgety in school. The very qualities that made him so tiresome—curiosity, hyperactivity, recklessness—are precisely the ones that get him the girl, win him the treasure, and make him a hero. Even Huck Finn is all right at the end of his story. Although he never learns to tolerate “sivilization,” he knows he can head out to “Indian territory,” to the empty West where even the loose rules of Missouri life won’t have to be followed.”

  4. As I said elsewhere (and without reference to earlier comments):
    I thought they were releasing a new edition 2005ish, or at least there were proposals for changes. I have (somewhere) articles from then as I was working for a counselling service – DSM is used extensively outside the USA but is not an internationally agreed standard, just a US one. It was interesting to see new illnesses surface and old ones get struck off. (Wish I could remember what I had my eye on but the changes from DSM-IV to -IVTR are listed at though, on second thoughts the changes I was hearing about might have been due to the adoption of the DMS standard instead of the one company psychiatric staff had been using beforehand).
    By defining illness the standard effectively rules on what a well mind is and the changing boundaries seem, in some areas, more down to sociological or cultural shifts than understanding of the mind. With the US curriculum debates in mind (e.g. ) those involved in the updates could profoundly influence personal freedoms worldwide.

    The Association is taking steps to maintain strong boundaries in other areas of medical ethics areas

    Nevertheless there is widespread disagreement over whether US-centred mental health diagnostics are universally applicable, partly because much of current psychiatric and counselling practices have based on US research outcomes (as the greatest volume of studies have been US-based), but repeat or similar studies elsewhere in the world have had different outcomes, and partly because eccentricity of a behaviour can be culture-specific.

    There are concerns that the forthcoming changes are insufficiently founded on research and concerns with the entire DSM system

    Personality disorders are particularly prone to redescription when editions are revised

    ‘Following changes to the previous version of the DSM, there was a rise in rates of attention deficit hyperactivity disorder, autistic disorder and childhood polar disorders. ‘ (see Guardian link below). Such changes affect statistics on mental health incidence and, as you say, the labels have all sorts of impacts on individuals.

    As you say, many feelings which are normal can be abnormal when extreme and prolonged, but my understanding is mental health diagnostics is based on behaviours rather than feelings – while linked, the distinction is important.

  5. @Matt The ‘prescribe first’ approach to mental health is highly problematic. Even where people in the UK get access to counselling therapies for depression (now more available than ever before but how much longer this will continue with the present cuts remains to be seen) they’ve often been prescribed anti-depressants before it starts. Critically, if the antidepressant prescribed to an individual doesn’t turn out to fit their personal neurochemistry, increased depression is nearly always among the most prevalent and significant side effects – basically the wrong one makes you worse. Not all cases are amenable to anti-depressant fixes but where a pharmaceutical can help and the right one is found, it is very rare for the personal fit to be the first one prescribed – no fault of the doctors as the right one depends on individual neuro-physiology and most treat more-or-less the same broad range of depressive symptoms. Trying out each failure usually takes months before its success is ruled out (unless if there’s a rare immediate and severe bad physical reaction).

    As a result, when counselling becomes available, a significant cause of the patient’s degree of depression can be the effect of a pharmaceutical intervention which counselling won’t be able to remedy.

    Psychiatric professionals I’ve worked with have questioned whether prescription early on after a depression diagnosis interferes with (or prevents) any natural self-adjustments in neurochemistry which might provide a basis for longer-term health. Obviously this isn’t an issue where the problem has already lingered and failed to respond to drug-free therapies for a significant period.

  6. There is a danger, perhaps, in being too quick to say that someone is ill, when they simply manifest a normal tendency to an unusual degree. Doing so might make them feel stigmatize and lead to unnecessary medical interventions.

    Flipped around, it can be argued that the recognition that everybody has mental failings could help to de-stigmatize mental illness. By showing that the line between health and sickness is blurred, it makes the distinction between those on one side and the other less harsh.

  7. Antonia,

    That is certainly a tricky problem you identify. When dealing with individuals, we cannot use the best tools of science (based on controlled, double blind experiments). As such, there will always be doubt about cause and effect.

  8. Nearly One Million Children in U.S. Potentially Misdiagnosed With ADHD, Study Finds

    ScienceDaily (Aug. 17, 2010) — Nearly 1 million children in the United States are potentially misdiagnosed with attention deficit hyperactivity disorder simply because they are the youngest — and most immature — in their kindergarten class, according to new research by a Michigan State University economist.

    These children are significantly more likely than their older classmates to be prescribed behavior-modifying stimulants such as Ritalin, said Todd Elder, whose study will appear in a forthcoming issue of the Journal of Health Economics.

    Such inappropriate treatment is particularly worrisome because of the unknown impacts of long-term stimulant use on children’s health, Elder said. It also wastes an estimated $320 million-$500 million a year on unnecessary medication — some $80 million-$90 million of it paid by Medicaid, he said.

    Elder said the “smoking gun” of the study is that ADHD diagnoses depend on a child’s age relative to classmates and the teacher’s perceptions of whether the child has symptoms.

  9. You are perceptive in pointing to some of the problems of medicalizing mental illness, and I agree with your other points at the top of this disucssion.

    One problem with ADHD kids is that the parents of Tom Sawyer types are much less likely to be tolerant enough of that type of energy…not to blame them though. I wondered what specifically caught your eye about this study and where your interest is?

    Here’s an interesting article that addresses social perceptions of mental illness and stigma, The Americanization of Mental Illness.

    Be well!

  10. I wondered what specifically caught your eye about this study and where your interest is?

    The ADHD study seems like a perfect demonstration of normal mental variation being inappropriately categorized as mental illness. This is clearly illustrated by how teachers see the relative immaturity of younger children in their classes and conclude that they have ADHD:

    For instance, in Michigan — where the kindergarten cutoff date is Dec. 1 — students born Dec. 1 had much higher rates of ADHD than children born Dec. 2. (The students born Dec. 1 were the youngest in their grade; the students born Dec. 2 enrolled a year later and were the oldest in their grade.)

    Thus, even though the students were a single day apart in age, they were assessed differently simply because they were compared against classmates of a different age set, Elder said.

  11. Flipped around, it can be argued that the recognition that everybody has mental failings could help to de-stigmatize mental illness. By showing that the line between health and sickness is blurred, it makes the distinction between those on one side and the other less harsh.

    It would be good to see some empirical research on this: as the proportion of the population considered to have a mental illness increases, does the level of stigma surrounding mental illness increase or decrease?

  12. Can Preschoolers Be Depressed?

    Is it really possible to diagnose such a grown-up affliction in such a young child? And is diagnosing clinical depression in a preschooler a good idea, or are children that young too immature, too changeable, too temperamental to be laden with such a momentous label? Preschool depression may be a legitimate ailment, one that could gain traction with parents in the way that attention deficit hyperactivity disorder (A.D.H.D.) and oppositional defiant disorder (O.D.D.) — afflictions few people heard of 30 years ago — have entered the what-to-worry-about lexicon. But when the rate of development among children varies so widely and burgeoning personalities are still in flux, how can we know at what point a child crosses the line from altogether unremarkable to somewhat different to clinically disordered? Just how early can depression begin?

    The answer, according to recent research, seems to be earlier than expected. Today a number of child psychiatrists and developmental psychologists say depression can surface in children as young as 2 or 3. “The idea is very threatening,” says Joan Luby, a professor of child psychiatry at Washington University School of Medicine, who gave Kiran his diagnosis and whose research on preschool depression has often met with resistance. “In my 20 years of research, it’s been slowly eroding,” Luby says of that resistance. “But some hard-core scientists still brush the idea off as mushy or psychobabble, and laypeople think the idea is ridiculous.”

    For adults who have known depression, however, the prospect of early diagnosis makes sense. Kiran’s mother had what she now recognizes was childhood depression. “There were definite signs throughout my grade-school years,” she says. Had therapy been available to her then, she imagines that she would have leapt at the chance. “My parents knew my behavior wasn’t right, but they really didn’t know what to do.”

  13. The authors of DSM-V attempt to capture this less than black-and-white picture by dispensing with the approach taken in previous DSMs, which was based on cut-and-dried checklists of symptoms. Instead, they have adopted a “dimensional” approach, in which patients are assessed for symptoms besides those that match their principal diagnosis, as well as for the severity of their symptoms.

    One of the goals is to help medics identify mild forms of severe illnesses such as schizophrenia before people have experienced their first serious psychotic episode, in the hope of stopping the disease progressing. But DSM-V will also propose new conditions, such as “complicated grief”, which describes bereaved people who may benefit from being treated as if for major depression.

    The aim is to help doctors offer patients the most appropriate treatment. But an important by-product will be that researchers working on the psychiatric drugs of the future will be able to test them in genetically engineered animal models that more closely resemble human reality. The importance of this was underlined by Eric Nestler of the Mount Sinai Medical Centre, in New York, and Steven Hyman of Harvard University in this month’s Nature Neuroscience, when they wrote that drug development for schizophrenia, major depression, bipolar disorder and autism “is at a near standstill”.

    The proposed changes, however, worry some psychiatrists, who see in them a creeping medicalisation of normal behaviour. They point out that the DSM carries a lot of weight. Pharmaceutical companies devise new drugs for the conditions it defines, lawyers use it to sue doctors, ordinary people use it to diagnose themselves. They fear that by blurring the boundary between health and disease, DSM-V loses sight of a doctor’s first duty: to do no harm.

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