Brent Bambury at CBC News reports (Excerpt):
The American Psychiatric Association sent shivers through the mental health community last week when it said it was re-examining its list of disorders and would be proposing a more narrow definition of autism, one that might exclude up to three-quarters of the cases that exhibit milder symptoms.
Understandably, parents and caregivers of autistic kids worried that the new definition might shut the door to expensive treatments for children who have been diagnosed with the condition in ever-greater numbers in recent decades.
In some ways, the adjustment is editorial. The APA is in the midst of updating the Diagnostic and Statistical Manual, the giant standard reference of mental disorders, where all mental illness is assigned universal definitions, for the first time since 1994. Often called the bible of psychiatry, the DSM is cited clinically in courts and by insurance companies to determine the extent of treatment that might be offered and is itself not without controversy.
In a mere 50 years it has gone from being a manual of just over 100 pages that defined 103 disorders to its current, fourth edition, that is 886 pages in length and lists 374 known mental disorders.
It also has the unenviable reputation of having been sharply criticized by two of the eminent practitioners who oversaw the DSM expansion in its earlier stages.
"What's funny about the DSM, and critics of psychiatry always point this out, is that DSM-1 was a tiny little pamphlet and DSM-2 was bit bigger," says Jon Ronson, my guest this week on CBC Radio Day 6.
"By the time it got to DSM-4, it was just vast. It was bigger than the New Testament and the Old Testament and the Talmud all put together."
Ronson is a writer and documentary maker whose books The Psychopath Test and The Men Who Stare at Goats look closely at behaviour that defies the rational.
In The Psychopath Test, his most recent book, I thought I detected some skepticism about the DSM and its centrality in modern psychiatry. But his take is more nuanced than some.
It was DSM-4, the current, gargantuan edition that added Asperger syndrome as an autism-spectrum disorder in 1994.
Since then, the number of reported cases has exploded and the man who headed the task force that created DSM-4, Dr. Allen Frances, currently professor emeritus at Duke University, has been highly critical of his own work.
He told Ronson that the inclusion of Asperger was a mistake and he has also had some sharp advice recently for the task force working on DSM-5.
"Anticipate the worst. If something can be misused, it will be misused," Frances told National Public Radio in the U.S. "If diagnosis can lead to over-diagnosis and over-treatment, that will happen. So you need to be very, very cautious in making changes that may open the door for a flood of fad diagnoses."
False epidemics
Dr. Frances told Ronson that he and his associates had created three false "epidemics" — childhood bi-polar disorder, autism and ADHD.
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While we must not understate the dangers of pathologizing behaviors and experiences that lie within the range of healthy human experience and functioning, we must also be sensitive to the dangers inherent in narrowly construed criteria for diagnosis. Third party payors require discrete labels in the form of ICD/DSM diagnoses in order for care to be provided and they are financially motivated to deny care that improves quality of life while having little obvious effect on decreasing overall cost. The potential negative impact of a mental health diagnosis is a genuine concern for all clinicians, particularly those with a humanistic orientation. At the same time, the negative impact of being denied treatment is also a concern for anyone who has seen the benefits of quality interventions and the effects of untreated psychological problems which may or may not fit neatly into diagnostic categories. Some insurance plans deny or reduce care for adjustment disorders , describing them aas non-biologically based. Until policy changes occur that allow for access to psychological services without the need for categorization and labeling, clinicians will be torn between these two real concerns. The negative impact of stigmatization arising from a diagnosis is a barrier to treatment that humanistic psychology must remain sensitive too. At the same time this barrier serves third party payors through reduced utilization. While we continue to address the problems arising from categorizing individuals we must be careful to avoid the pitfalls inherent in the pathology based system of healthcare currently in place.
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