17 mars 2010
The original DSM series was motivated by an attempt to correlate several conflicting classification schemata (such as still persist in the ICD). However, since the American Psychiatric Association was taken over by a set of narrow specialists in neurobiology in the 1940s (Kirk and Hutchins) it has become an ever more inflexible instrument. In general – with a few notable exceptions such as the grudging acceptance of homosexuality as normal behavior (the topic of a brilliant episode of This American Life) – each edition has been worse than the last. The new edition promises to continue this proud trend.
Before going into some particular changes for this edition, let me rehearse two problems with the entire set. A significant logical flaw is that it is entirely self-fulfilling: psychiatrists, psychologists and patients can only get re-imbursements for sessions attached to a specific DSM diagnosis. There can be no disagreement with the code, even if the whole is largely flawed. In my own experience and that of my friends, this generally means that we sit down with our psychiatrist during a session and choose a code which will do relatively little professional damage if it gets out, and will provide the drugs that she and I prefer. I know a large number of psychologists and some psychiatrists (the non-pill-pushing variety) who find this a tad abhorrent. Further, and again I’ll speak for myself as patient, I find the current set of available conditions massively restricting. When going through what your average Australian would call a 'rough spot' several years back, I was offered variously diagnoses of depression, hypermania, hypomania, manic depression, ADHD, anxiety, hyperthyroidism and anhedonism – I deeply prefer the nineteenth century offerings of melancholic, bustling, a delicate sort: each with their own social acceptance and romantic overtones. Bateson's definition of information (a difference which makes a difference) does not obtain here, since most ascriptions of these classifications lead to the prescription of a very small set of drugs.
I am feeling ever more constrained to always keep my behavior within acceptable limits. In the nineteenth century I could, in my Sherlock Holmes persona – but maybe I’d better not talk about that one - fall into a black depression, shoot up some cocaine and play the violin then come out of my funk and rid the world of Moriarity. Today, that archcriminal would quickly get me hospitalized. In short, the medicalization of deviance – a term first deployed in the 1970s – is in its heyday. Where the United States still manages to see itself as a haven for liberty, I wonder how one can maintain that rosy façade in the face of the medicalization of the minds of most of our population and the largest incarceration and execution rate (the only really competing paradigm in the United States to DSM is mortal sinners vs nice people) in the developed world.
Enough of a rant perhaps. Let’s take as given a tradition of not recognizing social, communal and family dimensions of difficult internal lives of citizens. I find it hard to be truly beatific in a world bent on ecological self-destruction and living in a society bent on unjust wars and providing no safety net for its poorest citizens so that many die unnecessarily, but I guess that’s my fault. It’s sad, but fortunately I have some happy pills.
I actually rather like the potential dissolution of Asperger’s syndrome into Autism Spectrum Disorder - despite the shocked reaction of parents of some computer geeks, who are often characterized by some forms of behavior associated with Asperger’s (just visit the Google campus for a day to verify this). These are clearly part of a package of behaviors which run the full gamut from what should be considered normal to that which is definitely problematic. If I had a general theory of what is called mental illness I would take this principle as a baseline: it’s spectrums all the way down. That’s what multidimensionality is all about. I do find some fault with Susan Swebo’s report though – what exactly does it mean to cleave to a principle that collapses without disambiguating:
"How to address Pervasive Developmental Disorders – Not Otherwise Specified (PDD-NOS). The individuals currently diagnosed with PDD-NOS may still be described in DSM-V, but the work group will discuss whether they can redefine ASD in such a way that the PDD-NOS diagnosis isn’t necessary, as this diagnosis currently captures a very heterogeneous group of individuals."
If I understand the logic of this (though I’m getting depressed as I write so please don’t pay any attention to me), this means that a heterogeneous group of individuals will become homogeneous (which basically means treated by the same drugs) if we wiggle the definition of ASD. And this is seen as a breakthrough rather than sweeping interesting problem cases under an available carpet?
I am not totally negative about this revision. Indeed, I close on a somewhat hopeful note. There are revisions being suggested to the definition of just what a mental disorder is, which include:
"C Must not be merely an expectable response to common stressors and losses (for example, the loss of a loved one) or a culturally sanctioned response to a particular event (for example, trance states in religious rituals)
D. That reflects an underlying psychobiological dysfunction
E. That is not primarily a result of social deviance or conflicts with society"
If in practice we really honored C and E and defined D in some useful way (which would have to go way beyond psychobiological) then we might work towards a socially useful and culturally rich treatment of mental disorders. First, though, the psychiatric community needs to come up with rich treatments of C and E, since currently childhood deviance or conflict is not seen in this way (even though it’s of the nature of adolescence) and the set of ‘common stressors’ and ‘culturally sanctioned’ do not include living in an overcrowded world (which we know, through rigorous study, causes problems for rats).
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