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Is there a moral argument for including more common behavioural phenomena in the DSMV?

“Shyness, bereavement and eccentric behaviour could be classed as a mental illness under new guidelines, leaving millions of people at risk of being diagnosed as having a psychiatric disorder, experts fear,”

reads the title of a news article earlier this month in the wake of the publication of the most recent draft of the American Psychiatric Association’s proposed revision to the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is used as a handbook for psychiatrists in the United States.

With this blog post, I hope that we can begin a discussion of a) the reasons undergirding fears of being “diagnosed as having a psychiatric disorder” and b) whether  – counter intuitively – there might be a moral reason to include common behaviors in the DSM,  because doing so might  help us avoid these feared consequences.

Let us start by noticing the ambiguity in the above news title: are they talking about bereavement etc. being included as separate categories or are they newly being allowed into existing categories like depression? As we shall see, which understanding we assume makes a big difference in our moral evaluation.

It seems from a quotation in the article that fears stem from expanding existing categories: “there is a real danger that shyness will become social phobia, bookish kids labeled as Asperger’s and so on.” And in an article in the medical journal, the Lancet, on the same topic (summarized here by the telegraph):

“Previous DSM editions have highlighted the need to consider, and usually exclude, bereavement before diagnosis of a major depressive disorder. In the draft version of DSM-5, however, there is no such exclusion for bereavement, which means that feelings of deep sadness, loss, sleeplessness, crying, inability to concentrate, tiredness, and no appetite, which continue for more than 2 weeks after the death of a loved one, could be diagnosed as depression, rather than as a normal grief reaction.”

We might think of this “miscategorization” concern in two parts: 1) that two unlike people might be grouped as having the same thing and 2) that someone without an illness or disorder might be categorized as someone with an illness or disorder. The crux of the miscategorization concern (though there are other elements) seems be about 1) Inappropriate treatment and 2) Stigmatization.

1) Inappropriate treatment: In the Telegraph article Allen Frances of Duke University illustrates,

“DSM5 will radically and recklessly expand the boundaries of psychiatry. Many millions will receive inaccurate diagnosis and inappropriate treatment.”

In the Lancet piece we see that the concern is specifically about psychoactive drugs:

 “Medicalising grief, so that treatment is legitimised routinely with antidepressants, for example, is not only dangerously simplistic, but also flawed. The evidence base for treating recently bereaved people with standard antidepressant regimens is absent.”

The idea is that certain treatments (i.e. antidepressants) were developed with an evidence base (shown to be effective) only for a specific population. These treatments have real risks and side-effects. Use outside the specific population, therefore, would put many at risk of harm with uncertain or no benefit. [Many argue that this has already been happening over the years within most psychiatric categories, which have become heterogeneous groups of people who may share neither symptoms nor underlying mechanism.] Some are particularly concerned that this all-enveloping strategy is prompted by the pharmaceutical industry to increase profits.

2) Stigmatization: Those currently diagnosed with psychiatric illness struggle with self and other-imposed stigma, which can have significant negative impact. The concern is that people with bereavement etc. would become stigmatized. Most would agree, however, we should do what we can to decrease this stigma and its harms. This stigma arises from many causes, among them the grim social history of psychiatric illness, current fear and misunderstanding, and the beliefs that mental illnesses and disorders are severe (often requiring hospitalization), unlikely to get better (requiring life-long treatment), and of unknown/mysterious causes. Might it be that these beliefs underlie the intuition that conditions like bereavement are just a part of “normal living” or “being human?” and should therefore not be thought of as mental disorders (as quoted from the telegraph articles)?

 “We need to be careful not to overmedicalise experiences that are part of normal living, and to make sure we allow people to grieve rather than try and suppress it or treat it.”

“Grief is not an illness; it is more usefully thought of as part of being human and a normal response to death of a loved one.”

In other areas of medicine, interestingly, we have examples where “normal” responses to traumatic incidences are thought of differently from the way they are thought of in the above quotations. Consider the body’s immune response to infection, the natural response to breaking a bone by falling out of a tree, or to brushing up with poison ivy, poison oak, or a jelly fish. We recognize that these are normal responses that often serve a purpose, but that they would benefit from appropriate medical care (and that it would be inappropriate to treat a broken bone simply by numbing the arm, as this might lead to continued arm use and suboptimal healing, just as we might think it inappropriate to simply numb the emotional pain due to bereavement).  Also, we have things like flat-feet, near-sightedness, hypertension, and eczema, that might be thought of as mild but can benefit from orthotics, glasses, low-salt diets, and moisturizing creams. Do we have a bias against thinking that mental conditions that may get better with time, that may not require heavy-duty treatment or hospitalization, and that have identifiable causes might be similarly regarded as disorder/illness?

The concerns of inappropriate treatment and stigmatization loom large if we swell the already bloated bellies of existing diagnostic categories. But might it be possible that including more specific examples of conditions that might benefit from attention but do not fulfill the negative stereotype of mental disorder would decrease both the likelihood of inappropriate treatment and overall harm done by stigma?

By clearly delineating individual categories for this type of trait or normal reaction to traumatic event we could theoretically:

1) Decrease the likelihood of misplacing people into the established categories of mental disorder/illness, as these phenomena would have their own clear categories

2) More easily identify and discourage inappropriate treatment. Because they are separate from categories like depression, it should not be assumed that they would respond to treatments used for other populations. Any use of drugs like antidepressants would be more clearly seen as not-evidence based and inappropriate

3) Help people receive appropriate support and attention. we see this desire in the lancet: “For those who are grieving, doctors would do better to offer time, compassion, remembrance, and empathy, than pills” But it was especially illuminating to read the following reader comment to the telegraph article summarizing the lancet piece:

“[sadly, it is common that] The effects that the death of a parent can have on an individual of any age are grossly undermined and support is often lacking. As soon as the funeral is over the bereaved is expected to return to their normal life as if nothing has happened and to return to all the usual work stresses many of which can be much harder to deal with shortly after bereavement. Acknowledgement of the situation with understanding and the availability of support, if needed, would go a long way in helping to prevent prolonged or delayed grief and all its complications.”

4) The inclusion of more common conditions that are mentally based (and are mild, get better with time, or have known causes) might combat the negative stereotypes and fear that give rise to the stigma surrounding “diagnosis with mental illness” that does not surround “diagnosis with a classically physical condition.” This would bring mental health more in line with physical health where there is less of a black and white binary of “ill or not” (nearly a quarter of the UK population has the physical disorder, hypertension). It also might help create a more supportive community and increased familiarity with mental health issues. Though more people in total would experience some sort of mental condition at some point in life by including these new definitions, and thus experience some level of stigmatization, the overall harms might actually decrease if we can decrease the average level of stigma.

The moral argument that follows from reasons 1-4 –counter intuitive though it may be – deserves consideration; empirical components of these reasons (which would build evidence for or against the “might” clauses) should therefore be investigated.

I would be grateful to you, the readers of the practical ethics blog, for your thoughts on the moral argument that if we desire to decrease the harms of inappropriate treatment and stigmatization in mental health, we should consider including in the DSM more common behaviors that would benefit from care.

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3 Comment on this post

  1. I think there are much better moral arguments against the type of thing that you are suggesting here rather than for it. I'm saying, in fact, that what you are suggesting falls on the bad side of most ethical arguments. You would be encouraging more medicalization of society, but I don't think the idea of transforming the world into a gigantic hospital would represent a great improvement by any means. As things stand there now, there is a great deal of iatrogenic disease at present in medicine. What I'm saying here is that a great number of people are killed off by their "treatment" rather than their disease, and that's many times when they have an actual disease. Unfortunately, continuing the line started by the DSM-III and IV means exactly that, more iatrogenic disease, promoting this bad, and essientially damaging, behavior on the part of mental health professionals. Psychiatric disability payments have been on the rise for decades, but this increase creates an unnecessary burden on the economy maintained by people who are not deemed "sick". It is not inconceiveable that increasing the numbers of people on disability in this fashion could eventually lead to economic collapse and national decline. I think you've got a better and much more moral argument for "treating" members of the APA before they suck more members of the general public into "treatment" by medicalizing more and more common behaviors.

  2. Hello Matt,
    I think that you are right on two important points: 
    The first is in distinguishing the false diagnosis problem from the stigmatization one. The second is to try to draw parallels between mental health and physical health problems (leaving aside for the sake of simplicity the complex interactions between the two).

    Starting with the second point, one similarity is that people decide to become patients for one of two reasons : their affliction handicaps or at least annoys them so much that they want treatment; or they seek diagnosis because they fear that their condition is symptomatic of a potentially serious problem. There are also occasions when people become patients without deciding : they collapse, are victims of an accident and other people decide (at least temporarily) for them. I have no statistics on this, but I guess that there are more mental health referrals that are largely due to other people’s decisions or influence than in the case of physical health.

    One danger of expanding the DSM is that it encourages OTHER PEOPLE (such as parents) to see slightly abnormal behaviour as symptoms of official, labelled, “mental health problems”.
    To quote from an article by Marcia Angell in the NYRB (Juky 14 2011):
    “The apparent prevalence in the USA of “juvenile bipolar disorder” jumped forty-fold between 1993 and 2004, and that of “autism” increased from one in five hundred children to one in ninety over the same decade. Ten percent of ten-year-old boys now take daily stimulants for ADHD—”attention deficit/hyperactivity disorder”—and 500,000 children take antipsychotic drugs

    Turning to stigmatization, your argument seems to be based on the concept that if everyone is described as having a mental health syndrome listed in the DSM, we will no longer stigmatise those who suffer from related mental health problems. I guess that having myself grieved I have empathy for others who grieve, but I doubt that it will stop me drawing a line somewhere between “normal” grief and an incapacitating depression which though occasioned by grief, is probably something different and which requires medical help. 
    I agree totally that this should not be seen as stigmatizing, but attacking the stigma of mental health problems is more complicated than listing grief as a pathology or potential pathology.

  3. I'm finishing my social work degree, so this sort of thing affects my future work.

    At least in the United States, many insurance companies don't cover visits to a therapist without a diagnosis. Therapists will sometimes assign a vague diagnosis like "adjustment disorder" (which can cover grief and any other life difficulties). The diagnosis must be given on the first session or there can be no further sessions (unless the client can pay out of pocket). So, faced with a client experiencing normal grief, who might benefit from talk therapy, many practitioners apply a diagnosis they knew to be inaccurate. I don't blame them. The client probably never knows they've been diagnosed with anything unless they ask, so it's hardly stigmatizing.

    But classing grief as a kind of major depressive disorder makes no sense. It does not have the same cause and does not need the same treatment, any more than depression caused by a medical condition like hypothyroidism should be called major depressive disorder. We already have a catch-all diagnosis that can be used for insurance purposes, and depression is not it.

    I work at a mental hospital, and it hurts to see the stigma people with serious mental illness carry about themselves and others like them. I would love to see more public acknowledgement that mental illnesses are common and not as scary as we think they are. But over- or mis-diagnosing is not an appropriate way to fix this problem.

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