Psychiatry Confuses Distress with Disorder

A front-page story in the March 24, 2008, edition of The Vancouver Sun warned readers of a new and potentially devastating epidemic.

Headlined "Mental health problems soar on campus," the story explained that some universities have seen a tripling of mental health patients in the past decade, and that students with "mental health disabilities" are the "fastest-growing group in most institutions."

Now, despite their being famous for drinking games and toga parties, it is a little hard to believe that university students are collectively losing their minds. Fortunately, amid all the alarming and alarmist statements in the story, there was one dissenting voice: Stanley Kutcher, a psychiatrist at Dalhousie University in Halifax, denied that there was any increase in mental illness on North American campuses.

Kutcher instead suggested that students are now seeking help to cope with the stresses of life, rather than because of mental illness: "The bar has been set lower," Kutcher said. "People are often going for assistance for distress, as opposed to disorder."

Kutcher's "diagnosis" could well extend well beyond university campuses, as we regularly hear of an epidemic of depression sweeping across the world. Indeed, the website of the World Health Organization warns that by 2020 depression will become the second-most common cause of disability, after heart disease.

Yet, as with the case of university students, there's reason to believe that this is a pseudo-problem: The rise in the number of people attending psychiatrist's offices could be the result of greater awareness of the services available, rather than because more people are suffering from mental illness.

Or perhaps there's a deeper explanation: Perhaps the way in which psychiatry defines and categorizes mental disorders has led to many mentally healthy people being diagnosed with an illness. This is the troubling conclusion of Allan Horwitz's and Jerome Wakefield's excellent new book The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder.

Horwitz and Wakefield certainly aren't the first critics to accuse psychiatry of pathologizing normal human behaviour and emotions. And if we consider the dramatic rise in the number of recognized disorders, it does seem that psychiatry has been gradually medicalizing the human condition.

For example, the first edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), published in 1952, listed just 106 disorders. The second edition (1968) catalogued 182 disorders, while DSM-III (1980) included 265. The fourth edition, published in 1994 and currently in use, lists 374 disorders, and many psychiatrists are pushing for the inclusion of additional ones in DSM-V, slated for publication in 2012.

Since it's unlikely that psychiatrists discovered so many new illnesses in such a short time, critics have charged psychiatry with intentionally expanding its province. Horwitz and Wakefield offer a much more nuanced argument.

The authors trace the problem back to DSM-III, which has been rightly called revolutionary. In the 1970s, when DSM-III was being prepared, psychiatric diagnosis was in crisis. Many studies had found that diagnoses were not reliable in that different psychiatrists would diagnose the same patient with different diseases.

This was an embarrassment to psychiatry which, as a branch of medical science, should have been able to provide consistent diagnoses. So to improve reliability and achieve scientific respectability, the DSM-III committee, under the leadership of Columbia University psychiatry professor Robert Spitzer, developed a dramatically different way of categorizing mental disorders.

While the first two editions of the DSM were heavily influenced by the then popular psychodynamic (Freudian) theory, Spitzer and his colleagues attempted to develop an atheoretical system that focused on symptoms. This, Spitzer reasoned, would help make psychiatry more scientific and improve diagnostic reliability, since symptoms are observable phenomena, unlike the hidden elements of the psyche that the Freudians emphasized.

As psychiatrist Sally Satel explains, it would be preferable to base a classification system on etiology (the cause of disease), but given psychiatry's still limited understanding of causes of mental illness, Spitzer was forced to rely on symptoms.

According to Horwitz and Wakefield, this is what gets the DSM into trouble. The authors note that the manual's emphasis on symptoms -- to the exclusion of the conditions that cause those symptoms -- blurs the distinction between "real" depression and sadness.

For example, the listing for major depressive disorder includes symptoms like depressed mood, loss of interest or pleasure, insomnia and weight loss, but doesn't distinguish between people who have those symptoms for no apparent reason -- which would seem to indicate a real disorder -- and those whose symptoms are caused by traumatic events.

The DSM does exempt from a diagnosis of depression people who have experienced the death of a loved one, but fails to acknowledge that people who have, for example, lost a job or been diagnosed with a serious physical illness will likely display symptoms of depression.

This doesn't mean they have a disorder; on the contrary, we would expect mentally healthy people to respond in this way to traumatic events. And while such people might well benefit from psychiatric care, Horwitz and Wakefield maintain that by failing to consider the causes of depressive symptoms, the DSM effectively transforms normal sorrow into depressive disorder.

Further, while Horwitz and Wakefield focus on depression, their critique applies to many of the disorders in the DSM given its near exclusive focus on symptoms. This means that we are probably grossly overestimating the number of people suffering from mental illness.

So while perhaps solving the problem of psychiatric diagnoses' lack of reliability, the DSM-III creates a more serious problem concerning the validity of diagnoses -- that is, psychiatrists might well be diagnosing illnesses that don't exist. Or as Horwitz and Wakefield put it: "The reliability might just represent everybody together getting the same wrong answer."

This wouldn't necessarily be a serious problem if the DSM's influence were confined to hospitals and psychiatrists offices, as good psychiatrists know better than to attend inflexibly to what the manual says. But it is a serious problem since the DSM has more influence on our culture than nearly any other book.

In addition to its use in medicine, the DSM is employed by insurance companies, government health plans, pharmaceutical manufacturers and regulators, social service agencies, courts, prisons and schools. Even patients are influenced by the DSM, as the manual's dominance in the culture leads people to reinterpret their problems as the product of bad brain chemistry rather than bad conditions or decisions.

This places a considerable burden on taxpayers, as health care costs rise when people are treated for non-existent disorders. Further, while some people -- particularly children -- are in danger of being overmedicated, others suffering from real and serious illnesses may have to wait in long lines before receiving treatment.

Horwitz and Wakefield also note that as long as psychiatry fails to acknowledge the social causes of patients' symptoms, psychiatrists will similarly fail to advocate for the elimination of the social conditions, such as broken homes and poverty, that cause suffering. This is a million miles from the Freudian psychoanalysts, who believed they had a responsibility to change the world.

Fortunately, the problem of overdiagnosis is not beyond resolution. The causes of mental illness will likely remain elusive for some time, but if the DSM-V counsels psychiatrists to at least consider social causes, then psychiatry can return to the noble work of helping ill people get healthy instead of making healthy people sick.

pmcknight@png.canwest.com