Feb 04 2013

DSM-V – Mental Illness vs Normal Behavior

The coming fifth edition of the Diagnostic and Statistical Manual (DSM-V) has rekindled debate over the legitimacy of the very concept of “mental illness.” A recent article by Peter Kinderman, a professor of clinical psychology, takes a strong position against the “mental illness” approach, writing:

But diagnosis and the language of biological illness obscure the causal role of factors such as abuse, poverty and social deprivation. The result is often further stigma, discrimination and social exclusion.

This is a healthy debate to have, as the concepts involved are tricky and there are real implications for societal perception, insurance coverage, and treatment strategies. I do not, however, share Dr. Kinderman’s position, which in my experience is fairly typical for a clinical psychologist. He is essentially saying that his profession’s approach to the question of mental illness is superior to the psychiatric profession. While the debate is legitimate and important, I can’t help feeling that there is a major component of a turf battle here also.

The question is essentially how we should think about symptoms of mood, thought, and behavior. At one extreme we night consider all aspects of human mentality as being part of the normal spectrum, with differences being just that – differences. Those who follow the position of Thomas Szasz consider labels on mental differences to be largely politically and culturally motivated forms of repression.

At the other end is the obsessive partitioning of every nuance of human behavior into one or another abnormal category – the medicalization of all human problems. This may be connected to an overly reductionist approach to psychology, seeing all behavior in terms of neurotransmitters and brain function and giving insufficient attention to higher order situational and cultural factors.

In my opinion the best approach is something in the middle. There is a common pearl of wisdom in clinical science that, before you can recognize the abnormal you have to recognize the full spectrum of what is normal. So – on the one hand we need to recognize the full spectrum of human nature, accept less common and atypical forms of human mood, thought, and behavior, and also recognize the relative roles of biology, situation, and culture (and their interactions) in forming a person’s mental state.

On the other hand, the brain is an organ, it is biology, and it can malfunction biologically just like any other organ. Further, even a biologically healthy brain can be pushed beyond tolerance limits resulting in an unhealthy mental state. We can reasonably define “unhealthy” in this context (probably a more appropriate word than “abnormal”) as follows – a mental state that is significantly outside the range of most people, may represent the relative lack of a cognitive ability that most people have, and results in definable harm. That last bit is critical – it has to be harmful.

It is true that there is an unavoidable amount of subjectivity in the above definition. What is considered harmful? The trap here is that a culture can determine a behavior harmful simply because it does not adhere to the culture’s norms. For example, homosexuality might be considered harmful because it is not accepted by society. It is now generally recognized, however, that such a circular definition of harm is not adequate.

Most of the time harm is determined by the individual – they present for help because they perceive their current mental condition to be harmful. Alternatively, those close to the person may consider their mental state harmful. This is a trickier situation, and psychologists recognize that often the “identified patient” is not the problem so much as the dynamic within a family or other social group. However, some forms of mental illness, like a delusional disorder, may not (by definition) be apparent to the person themselves but obvious to those around them.

It’s easy to get bogged down in semantics in this area, and I am not saying that language is not important to how we think about such things, but semantics aside I think there is general agreement (Szaszians and Scientologists notwithstanding) that many people have mental symptoms that they find unpleasant or functionally impairing with which they would like help.

The important clinical questions are – how should we identify and categorize those with mental complaints, how should we approach research and diagnosis into underlying causes, and which therapeutic interventions are most effective? In my opinion these are independent variables. Beliefs about one question may bias our thinking regarding another – but they don’t have to.

Kinderman seems to think, however, that they are inextricable tied together, leading him to attack what I feel are several straw men. He writes:

Psychiatric diagnoses are not only scientifically invalid, they are harmful too. The language of illness implies that the roots of such emotional distress lie in abnormalities in our brain and biology, usually known as “chemical imbalances”.

I disagree. With respect to mental illness “the language of illness” is much more complex and nuanced than Kinderman is indicating. Many of the diagnoses in the DSM are “disorders” or otherwise contain no implication at all that the underlying cause is a chemical imbalance.

Kinderman is saying that a mental illness diagnosis leads to the assumption of a biological cause and therefore to a medical (pharmacological) treatment. Rather, he argues:

It is relatively straightforward to generate a simple list of problems that can be reliably and validly defined. There is no reason to assume that these phenomena cluster into diagnostic categories or are the consequences of underlying illnesses.

We can then use medical and psychological science to understand how problems might have originated, and recommend therapeutic solutions.

But this is already the accepted approach to mental illness – except the bit about categories, but more on that in a moment. The DSM essentially is the practice of generating a list of problems that can be reliably and validly defined. Sorting such lists into categories does assume a certain amount of clustering of symptoms, and it is really that clustering that Kinderman is opposing. I do not think he has made his case, however.

In reality psychiatrists understand that the categories, or clusters of symptoms, with labels in the DSM are partly labels of convenience – for research, clinical reporting, and insurance coverage. I have personally never spoken to a psychiatrist who thinks that the categories in the DSM are iron clad, or that patients really sort cleanly into these diagnoses. They are at best a first approximation, a starting point, which then need to be individualized to the patient.

Further, I think there is some legitimacy to the clustering. There are syndromes, clusters of symptoms that do tend to occur together. Then there is a great deal of individual variation around the common themes represented by these clusters (which are DSM diagnostic categories).

Most importantly, the question as to which therapeutic approach is most effective can be completely disconnected to how we approach labeling symptoms. Here we should follow the clinical evidence wherever it leads. What I see in the literature, and with practitioners that I have interacted with, is that most take a blended approach – using medication and therapy in some combination as necessary. Some patients may need just therapy, while others require medication. As with all areas of medicine – practitioners can argue endlessly about the optimal balance based upon existing evidence, and different specialties will have their differing biases.

Let us take one specific example to see how this all works in practice. Kinderman writes about the DSM-V:

A wide range of unfortunate human behaviours, the subject of many new year’s resolutions, will become mental illnesses – excessive eating will become “binge eating disorder”, and the category of “behavioural addictions” will widen significantly to include such “disorders” as “internet addiction” and “sex addiction”.

Kinderman thinks that “binge eating disorder” is really just excessive eating, an “unfortunate behavior” that should not be labeled as mental illness. Here are the proposed diagnostic criteria:

Both of the following must be present to classify as Binge Eating Disorder.[5]

  • Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances
  • Feels loss of control over eating during binge. In other words, they feel that they cannot stop eating and they cannot control what they are eating and how much they are eating.

Also, an individual must have 3 or more of the following symptoms:

  • Eats an unusually large amount of food at one time, far more than an average person would eat .
  • Eats much more quickly during binge episodes than during normal eating episodes.
  • Eats until physically uncomfortable and nauseated due to the amount of food consumed.
  • Eats when depressed or bored.
  • Eats large amounts of food even when not really hungry.
  • Often eats alone during periods of normal eating, owing to feelings of embarrassment about food.
  • Feels disgusted, depressed, or guilty after binge eating.
  • The binge eating occurs, on average, at least twice a week for 6 months.
  • The binge eating is not associated with the recurrent use of inappropriate compensatory behavior and does not occur exclusively during the course Bulimia Nervosa or Anorexia Nervosa.

The criteria are specifically designed to exclude people who simply overeat or who are overweight. You have to eat an “unusually large amount of food” over a short period of time, eating unusually fast, and usually to the point of physical discomfort. There is a real attempt here to identify those who are significantly outside the range of healthy human behavior, to the point that there might be an underlying problem.

And here is the conventional thinking about the underling cause:

“A correlation between dietary restraint and the occurrence of binge eating has been convincingly shown in several investigations.”

Research is trying to tease apart whether binge eating is due to an underlying problem with eating regulation, or if it is produced by dietary restraint (severe forms of dieting). There is no assumption of biology here, nor is there an assumption that the best treatment approach is medical. Kinderman’s examples do not support his premise.

Conclusion

The diagnosis of mental illness remains complex and challenging. I am not arguing that any profession (psychiatry, psychology) has it exactly right, but I do think that the mental professions generally take a thoughtful approach to the question of what mental illness is and how it should be approached.

I disagree with attempts to restrict the debate on mental illness using semantics (usually taking the form of objecting to the term “mental illness”). I also think there are many common straw men brought up in this debate. I was disappointed in Kinderman’s review of the issues, and found that he was largely tilting at these common straw men.

But when you get past the turf-war posturing and semantic arguments, I find there is actually widespread agreement on the important issues. Human mood, thought, and behavior are complex, there is a wide range of variation in what constitutes human mental states, and any thoughtful approach must consider circumstances, environment, culture, and biological considerations, including their complex interactions. Further, therapeutic approaches should consider the full range of potential interventions and should ultimately be evidence-based.

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