The Dangers of Diagnosis
by Marlaine White | Posted January 09, 2011
“Nearly 1 in 5 Americans had mental illness in 2009.” This recent CNBC online headline captured my attention.
The brief article that followed was based on a report by the Substance Abuse and Mental Health Services Administration, a federal agency (oas.samhsa.gov). The article repeats highlights from the agency’s report entitled “Results from the 2009 National Survey on Drug Use and Health: Mental Health Findings,” available in PDF form.
The article states that an estimated 45 million US residents had a mental illness, and 11 million had a serious mental illness, and that these numbers reflect increasing depression among the unemployed.
The article’s intention — to create alarm — is loosely veiled. If people do not have access to interventionist and preventive treatment, any number of woes can follow: “disability, substance abuse, suicide, lost productivity and family discord.” Lost employment equals lost health insurance equals a lack of access to treatment equals a crisis. The insinuation is that government should step in to close the treatment gap.
Finding this article was fortuitous. Only days before I had read an article in Skeptic magazine about the “foibles of the Diagnostic and Statistical Manual V” — the diagnostic guide for mental health practitioners. (For details, see “Prognosis Negative” in Skeptic, volume 15, number 3 , by John Sorboro, himself a licensed, practicing psychiatrist.)
The state of the psychiatric arts today, complicated by increased government control over our nation’s healthcare industry, should alarm all citizens, not just libertarians.
According to Dr. Sorboro, the upcoming version of the DSM will have a marked increase in diagnosable psychiatric disorders, which may include “compulsive shopping” and “Post Traumatic Embitterment Disorder.” But the problem with the DSM has to do with the validity of what it says.
To rectify the unscientific nature of prior versions of the work, the third version was intended to “increase reliability by standardizing definitions.” Still, critics maintained that “the rhetoric of science — rather than scientific data — was used by the developers of the DSM-III to promote their goal, and science did not support [their] claims.” In 1994, the DSM-IV was published, listing 297 disorders. The latest revision is set to increase that list. Yet according to Dr. Sorboro, almost “every major psychiatric construct is seen as being of questionable validity by a vocal group within the field itself[,] or outside it.”
Psychiatric disorders are supposed to be pathological constructs, as Parkinson’s disease is a pathological construct. For a construct to be valid, Sorboro states, it must differentiate itself from other pathological constructs and provide a theoretical framework for prediction and specific intervention. He likens psychiatric pathological constructs to the construct for fibromyalgia — “a loose collection of non-specific complaints.” Fibromyalgia lacks an underlying, identifiable pathology. So do psychiatric constructs.
Critiques of the DSM include claims that it’s a collection of “the moral objections of a group within power [who] desire to medically pathologize another group for self serving purposes,” and that it is “a-theoretical and purely descriptive.” Evidence in support of the former critique is that homosexuality was not entirely removed from the DSM’s list of mental disorders until the latter half of the 1980s!
A diagnosis based on the DSM is not a divination of pathology. The DSM is tautological. It describes. It does not explain. Thus, diagnosis is subjective, not objective. Sorboro uses bipolar disorders to illustrate. Bipolar I disorder appeared in the DSM-III in 1980, followed by Bipolar II Disorder, Bipolar Disorder NOS (not otherwise specified — that’s worrisome), and cyclothymia. There has been a correlative rise in the diagnoses of such disorders — one statistic that Sorboro cites is a 4000% increase in bipolar disorder diagnoses in children during the past decade, despite the fact that mental health practitioners know “hardly anything more of real scientific significance about bipolar disorder than we did in 1980.”
Soboro states that medical disease classification evolves in a messy and inconsistent way, “and often has to do with politics and not just compelling scientific fact. It’s just much worse in psychiatry.” For example, contributors to the DSM-V include “health care consumers”; and as Sorboro says, no other branch of medicine would ask consumers for advice in defining pathology. Moreover, the American Psychiatric Association taskforce handling this revision is conspicuously closed and non-transparent — task force members must sign confidentiality agreements and cannot keep written notes of their meetings.
I have been skeptical of the DSM since I first read it. I was a judicial clerk, and my judge kept a copy of the DSM-IV on one of his bookshelves. He used it for reference during sentencing hearings and when he presided over mental health hearings. During lulls in my clerkship tasks, I read several large chunks of the DSM-IV. My initial thoughts were: there certainly are some people with severe mental problems, but this is bullshit. Symptoms of the indicated mental “conditions” were so encompassing that anyone and everyone could be classified as having some type of mental disorder.
My best friend from high school is a psychiatrist, and after reading the DSM-IV, I asked her about it. She said that it gives a practitioner guidelines for diagnoses. But don’t guidelines have to guide? I asked. Isn't a diagnostic process that has no conceptual limits wholly subjective? The flu is marked by symptoms that make it the flu and not a common cold or pneumonia. But even a brief reading of the DSM shows that mental illnesses are not marked by unique symptoms. Why? My friend had a few forgettable justifications, but no answers.
Homosexuality was not entirely removed from the DSM’s list of mental disorders until the latter half of the 1980s!
Many Liberty readers are familiar with libertarian criticisms of the mental health industry. But the state of the psychiatric arts today, complicated by increased government control over our nation’s healthcare industry, should alarm all citizens, not just libertarians. Psychiatric abuse by states against citizens is well documented; psychiatric imprisonment for dissidents in the Soviet Union is just one example.
The dangers are clear. In the legal realm, when a criminal statute is overbroad, behavior otherwise constitutionally protected is criminalized, subjecting more citizens to state control. Overdiagnosis of overinclusive mental disorders will subject more citizens to treatment — which, under Obamacare, means subjection to more government control. This should be enough to give anyone an anxiety disorder. Considering the political nature of mental “disease” classification, I wonder if a disorder marked by “irrational fear” of a “benevolent government” might be among the disorders included in the new DSM.
Marlaine White is a former government attorney completing a Ph.D. in international relations and comparative politics at the University of Maryland.
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