Since , also, these companies have been permitted to advertise their products, encouraging people to seek antidepressants directly from physicians. Horwitz and Wakefield prove that professionals have transformed normal sorrow into depression. And their results are meaningful because distinguishing between the two may just help reduce the stigma attached to sadness and depression, allowing people to seek professional help without carrying a diagnostic label. A more accurate distinction between the two would also allow public-policy money for treatment of mental illness to focus on those who are most gravely ill, and who have the greatest need.
Often it is this group that gets the least effective treatment. No one denies that major progress has been made in the treatment of the depressed; what we may have lost is the ability to address normal sadness not as a disorder, but as a challenge deserving of respect, care and appropriate interventions to help people regain their sense of well-being. Nancy Elman is emeritus faculty at the University of Pittsburgh. Her private practice focuses on couples and families. Read Next. This story has been shared , times. This story has been shared 85, times.
This story has been shared 52, times. Name required. Email required. Comment required. That would be the most honorable accomplishment of psychiatry and the mental-health field. Share Selection. Sara Stewart. Splitting is illustrated by the dismantling of the diagnosis of "phobic neurosis" in the DSM-II into five discrete diagnoses in the DSM-III: agoraphobia fear of places from which escape is difficult , simple phobia e.
In the future, however, the trend toward expanding the number of diagnostic categories may reverse. As brain-based etiologies of classic serious mental illnesses, such as schizophrenia and bipolar illness, are uncovered, psychiatry will probably lose those diagnoses to neurology. Perhaps one day psychiatry will cater only to patients suffering from existential crises. But not anytime soon. A word about the politics of diagnosis-making is in order. Over the years, DSM task forces have had to contend with bids, pro and con, for diagnoses such as masochistic personality disorder, sadistic personality disorder, pathological racial bias, and premenstrual dysphoric disorder a.
Soon, planners of the next edition, the DSM-V, tentatively scheduled for publication in , will hear appeals to create categories for shopping and food addictions. Internet addiction will surely come up too--as it did this summer at a meeting of the American Medical Association. Pro-life advocates hope to get the DSM to adopt "post-abortion syndrome" indicating pathological regret after terminating a pregnancy. Meanwhile, there is a battle over gender identity disorder, with some members of the transsexual community wanting it evicted, while others wanting it to stay in so that insurance companies will pay for sex-reassignment surgery.
All reparative enterprises, from medicine to car mechanics, prefer to have their nosologies organized according to etiology the cause of disease or pathogenesis the process of disease. In this way, the classification can offer guidance in fixing the underlying problem, or at least suggest productive avenues of research to develop new remedies. Nosologies based on symptoms are less desirable. Still, they were optimistic. It was the end of the s, a time of great but misplaced enthusiasm about the rapidity with which neuroscience would clarify whether the conditions did indeed differ from one another and from normalcy on the basis of underlying unitary pathophysiology or other root etiology.
Until then, even if they did not know what a disorder such as schizophrenia truly was, at least they could agree on a certain cluster of symptoms that would go by the name.
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In this manner, the DSM architects found themselves transported back to an earlier era in medicine. Over the centuries, as medicine progressed, diagnostic formulations shifted from superficial descriptions of conditions--which, at best, allowed physicians to render a prognosis--to identification of a verifiable mechanism of disease, which ideally would enable targeted treatment and prevention.
The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder downloads
Before the twentieth century, for example, schizophrenia and the insanity of tertiary syphilis were regarded as the same disease, because they were both characterized by psychosis. Yet when the cause of syphilis was found to be a spirochete bacterium, it was no longer classified as a mental disorder but an infectious one. A similar trajectory characterized Tourette's disease, a condition of vocal tics and uncontrollable explosive cursing.
When first described by the French neurologist Gilles de la Tourette in , the so-called maladie des tics convulsifs was understood to be the result of excessive alcohol and immoral activity in previous generations. Later, in the s, Tourette's was attributed to repressed masturbatory desire and bad parenting. By the s and s, however, psychiatrists began to accept a physiological origin for Tourette's once it was shown that tics often responded well to medication.
Psychiatry, alas, has a long way to go. A particular gene associated with bipolar illness was later discovered to occur in people with schizophrenia. The same goes for almost every other major finding--leading to the current hypothesis that these various genes confer risk for psychopathology, but not for any specific kind. Indeed, we still make diagnoses the old-fashioned way: by observing patients and talking to them. Andrea Yates, the Houston mother who drowned her five children in , had one of the most severe biological mental illnesses known to medicine--postpartum psychosis--and yet no brain scan or other objective, physical test could illuminate the clinical picture further, let alone diagnosis her.
Something had gone tragically wrong in Yates's brain. For Horwitz and Wakefield, such "wrongness" is central to their concept of a disorder. In a series of papers that Wakefield published beginning in , he developed a theory of mental illness called "harmful dysfunction" HD. The HD theory holds that disorders are genuine when they meet two criteria: they produce distress or impairment in the afflicted, and they are the result of a failure in a brain mechanism that prevents it from performing its natural function--that is, the function for which it was biologically designed by natural selection.
Thus, when a person experiences "normal" sadness, according to the HD model, nothing is broken, except perhaps his heart. Conversely, authentic depression major depressive disorder is the product of mechanistic failure. What might such failures be? One hypothesis regarding depression, for example, is that it is caused by a defect in the behavioral activation system.
This could account for apathy, dampened interest in both the seeking of pleasure and the person's capacity to respond to it. What we call panic disorder may have origins in a damaged threat-response mechanism. And some speculate that perhaps schizophrenia is a developmental failure of cognitive processing.
If the specific nature of the dysfunction element of "harmful dysfunction" seems vague, that's because it is. The simplest scenario would posit an errant gene behind the pathology, but that is not how psychiatric conditions work. Mental illnesses are the product of numerous genes that interact with one another, with the environment, and also with experience. A recent study by the National Institute of Mental Health found that eighty genes could be associated with bipolar disorder, eight of which influence how the brain responds to neurotransmitters such as dopamine.
Add to this the miasma of social and personal encounters that impinge upon the genetically vulnerable individual--stress, impoverishment, family instability, drug or alcohol use, and so forth--and the "cause" of mental illness becomes staggeringly complex and elusive. For more than a decade, the Wakefield HD theory has sparked vigorous debate among philosophers, psychologists, and evolutionary theorists. If disorder is a disturbance in an evolved function "intended" by nature, how can we know what nature intended?
Must these defects necessarily impair reproductive fitness to count as a dysfunction? Is it appropriate to rely upon standards of evolutionary fitness that developed under conditions that existed hundreds of thousands of years ago? Such questions are fascinating to academics--but less so to those who treat patients. Spitzer, a professor of psychiatry at Columbia University, was literally present at the creation.
And earlier, as a junior member of the same task force, he advised the board of trustees that homosexuality did not qualify as a mental disorder; he also wrote the position paper explaining the vote. Few people on this planet have spent more time wrestling with such questions. Yet in his essay the weary Dr. Spitzer admitted that, "I doubt that clinicians will ever be very concerned with what illness itself is Concerns with defining medical or psychiatric illness or disorder are generally left to sociologists, psychologists, philosophers of science, and members of the legal profession.
Front-line clinicians will not be joining the fray anytime soon. The academic debate over the evolutionary history of their patients' woes is irrelevant to everyday practice. Psychic pain often refuses to obey the procrustean demands of official classification schemes. A wise colleague of mine warns trainees at his medical school, "If you come to rounds and present a patient who fits the DSM criteria perfectly, I'll know you haven't really talked to him. Patients often have symptoms that sprawl across several diagnostic categories at once.
For example, 50 percent of kids who receive the trendy diagnosis of bipolar disorder also have ADHD. Over half of all patients with major depression also meet the criteria for an anxiety disorder. Does this mean that they suffer from more than one fundamental condition, or do they just appear to have multiple disorders because of the way the DSM has drawn boundaries around psychiatric symptoms? It is often impossible to know, because psychiatrists are not yet sure that the various named disorders signify distinctly abnormal brain mechanisms.
That is why good psychiatrists do not rely too heavily on the DSM. I do not mean to say that it is clinically irrelevant, however. As mentioned earlier, the distinction between schizophrenia and manic-depressive bipolar illness is important, given the role of lithium in the latter. Separating the depression of bipolar illness from major depressive disorder is important, too, given the risk of precipitating mania by treating a bipolar patient with an antidepressant.
It is also important to distinguish severe immobilizing depression the so-called melancholic subtype from other forms of depression, because electroconvulsive therapy ECT is extremely effective for that subtype. Another example is catatonia extremes of movement, from hyperactivity to passive mutism , which responds best to a Valium-type drug and to ECT.
But more often than not, treatment is not very specific. Consider depression. A psychiatrist will almost surely prescribe an antidepressant for a patient with major depressive disorder--this is obvious--yet the very same drug can be helpful in obsessive-compulsive disorder, eating disorders, and panic attacks. Perhaps this is because the drug's psychopharmacological properties are broad enough to affect multiple forms of pathology. Or perhaps it is because depression and the other disorders share a common defect far upstream in the causal chain.
Moreover, just as a single medication may ameliorate several different mental conditions, the converse is also true: a single condition may require more than one medication. The manic phase of bipolar disorder, for example, often requires a mood stabilizer and a sedating antipsychotic to control the excursions of mood, to combat accompanying paranoia, and to quell the agitation. So drug treatment is often guided less by diagnosis as such than by symptoms. In the end, the most we can say about mental illnesses is that they are the result of various interrelated causes unfolding at different levels of explanation: biological genetic or cellular , cognitive information processing , and psychological the generation of meanings in contexts.
Medications, talk therapies, and guided behavioral regimens bring their virtues to bear at these different levels. In this way, the full armamentarium of therapeutics can often be deployed with only a nod toward the DSM except to use its coding system for reimbursement, of course. Still, there is no denying the worrisome inroads made by a checklist mentality, especially in this era of rushed clinical encounters and the looming specter of the insurance form that requires listing a diagnosis.
In training programs across America, wise senior academic psychiatrists are reaching the end of their careers and retiring from teaching. This cohort is well versed in the psychodynamic tradition,yet enthusiastic about new medications and biological discoveries. As teachers, mentors, and department chairmen, they ensured that residents were trained in an eclectic fashion that combined descriptive, psychodynamic, and biological perspectives; that they learned how to listen and how to observe. The masters gently pried the DSM from our anxious fingers when, as residents, the manual was our beacon of orderliness in a roiling sea of desperately ill and sometimes frightening patients.
Now newer generations of psychiatrists have suffered as these seasoned men and women leave the field.
Major depression invites major concerns
The architects of the DSM were well aware of the potential for misuse. They cautioned against applying the manual mechanically and warned that it had to be complemented by clinical judgment, context, and patient history. They shunned any pretense of fixed essentialism and acknowledged that criteria chosen by group consensus to represent the diagnoses were based on clinical judgment and not yet fully validated.
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Similarly, they cautioned against manual users taking too literally the sharp boundaries drawn between disorders and between disorder and health. So who's afraid of the DSM? Not psychiatrists. Their primary goal is to relieve patients' suffering, and, with some important exceptions, it is symptoms, not formal diagnoses, that direct the clinician.
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In contrast, the DSM has had a powerful influence beyond the clinic. The impact has been felt, Horwitz and Wakefield observe,. In effect, these DSM definitions have become the authoritative arbiter of what is and is not considered mental disorder throughout our society. What might seem like abstract, distant, technical issues concerning these definitions in fact have important consequences for individuals and how their suffering is understood and addressed.
While clinicians can often make subtle, case-by-case assessments of their patients, many other social institutions demand more cut-and-dried approaches. Results published in revealed that 26 percent of all American adults qualified as having a mental illness within a given year. This sounds ominous, but a closer look shows that almost half had "mild" cases, often representing garden-variety anxieties and despair associated with problems in living--"emotional hangnails, " as the lead author of the study called them.
Horwitz and Wakefield devote a persuasive chapter, called "The Surveillance of Sadness," to describing efforts to gauge the amount of depression within the general population. The implications of sweeping mild cases into the wide net of epidemiological investigation are indeed worrisome. Clearly, investigators who survey broad populations need to guard against setting thresholds so low that they detect non-disorders and count them as real.
Unless they do, the estimates of mental illness make the problem look bigger than it is, thus ushering in intrusive new "tool[s] of emotional surveillance and potential misdiagnosis for each and every one of us. With suicide the third most common cause of death in fifteen- to twenty-four- year-olds about 4, annually , and with more than half a million adolescents making an attempt serious enough to warrant medical attention, screening would indeed appear to be an important public health mission.
Columbia University's TeenScreen is one popular program. Screening is conducted in two stages: teens voluntarily fill out a short questionnaire and are then interviewed by a social worker or a clinical psychologist, who verifies that a positive result means that the teen is truly struggling. If so, then the teen, with his parents' knowledge, is encouraged to undergo a more thorough evaluation.
In , the program screened 55, young people in forty-two states. About one-third of them screened positive on the questionnaire, and half of those--about 17 percent of all those screened--were referred for further evaluation after the clinical interview. The unintended result, Horwitz and Wakefield claim, is an "immense number of individuals who test positive on the pre-screen They worry that teen screening is a social program that is proceeding apace despite uncertain financial and societal trade-offs. The dangers of over-inclusiveness for both children and adults are obvious: needless prescribing of medications and gratuitous exposure to their side effects; wasting money on superfluous therapy and illegitimate disability claims; diverting physicians' services from the truly needy; creating bogus personal-injury lawsuits.
Granted, individuals seeking disability entitlements and redress for injury undergo detailed examination, not merely screening; but normal variants and mild versions of disorders can fit categories and count as official disorders nonetheless. These are problems in their own right, but the blurring of the distinction between normality and disorder has even wider societal implications. What that can also do is This is a great concern, particularly for parents.
Over the last decade, the numbers of children with bipolar illness and ADHD have exploded--or, more precisely, the rates of diagnoses for these diseases have skyrocketed. Yet how many of these children truly have a disorder? How many are simply exuberant kids who find themselves pushed over a diagnostic threshold by reacting normally to deprivation and chaos in their homes? As with depressed adults, misdiagnosing normal kids as disordered means they are needlessly medicated while precious mental health resources are diverted from children with genuine clinical needs.
In the end, diagnosing a population is a balancing act. Setting a threshold too low makes sick people out of normal ones, but compensatory efforts to raise the bar threaten to exclude people who truly are ill. The Loss of Sadness comes at a fortuitous time for American psychiatry. They would be wise to consider the work of Horwitz and Wakefield, and their demand that we avoid pathologizing normal reactions to the vicissitudes of life. Normal reactions to timeless human heartache are not the same as mental disorders.
Horwitz and Wakefield call for changes to major depressive disorder that would exempt patients whose depression is triggered by a serious loss, just as bereaved patients are ineligible for the diagnosis. This is certainly worth considering. But salvation does not lie within the DSM. It never did. As historians of psychiatry have pointed out, none of the four versions of the DSM issued between and came into being because front-line practitioners clamored for them.
Why would they? A compendium of diagnoses in which only a minority is directly linked with treatment will be of limited use to clinicians. Nor will changes in the manual enlighten the doctor-patient relationship.