Diagnostic inflation risks over-modulating our emotions and common behaviour
Exploring the current trend within modern psychiatry, and its implications for future diagnoses of mental health
Earlier this year, I came across a rather peculiar news piece that had landed on my newsfeed. I took a quick glance at the post, and the headline read: “American Psychiatric Association Makes It Official: ‘Selfie’ A Mental Disorder”. Now needless to say, this was indeed a satirical hoax (which had spread like wild-fire that day). However to me, the story raised a few important questions. Was it really that far-fetched to believe in clinicians diagnosing ‘selfies’ as a symptom of a much larger mental disorder? Absurd as it sounds, there may be some truth within this headline. Let’s forget ‘selfies’ for a minute.
The psychiatric world of today works in three major ways; research, education (training) of non-licensed psychiatrists, and applying the current clinical understanding of mental health via medical practice. Alongside this, there is also a heavy reliance on what some would call psychiatry’s “bible”, the Diagnostic Statistical Manual (or DSM for short).
And while the DSM has brought standardisation by categorising the criteria for mental health disorders, there has also been growing criticism of its effectiveness (even among the medical community). Psychotherapist Gary Greenberg, who has spent the last decade writing on the topic of the DSM, claims that the definitions for disorders mentioned in the DSM are “simply collections of symptoms that some experts agree constitute mental illnesses. There’s not a single diagnosis in DSM that lives up to the standards of medical diseases”. Greenberg is also not alone with this opinion. In a blog entry for Psychology Today, Dr. Allen Frances, former chair of the DSM-IV taskforce, alarmingly writes that somatic symptom disorder is defined so over-inclusively that it will misdiagnose “1 in 14 who are not even medically ill.”
Despite all this, under the weight of the American Psychiatric Association (APA), the DSM has endured through half a century as a core-component of psychiatry in the United States. And as such, has served as a framework for mental health diagnoses across the world. Still to this very day, the DSM is highly regarded and trusted by a wide spectrum of professional bodies, organisations, and authorities from pharmaceutical and health insurance companies to the legal system and policy makers.
For quite a while now, psychiatry’s tendency expand mental health categories has fed Big Pharma’s appetite for large profit margins. So much so that the question of publication bias and its ties to the pharmaceutical industry has been ushered forward by several academics such as, Ben Goldcare, a British physician who’s leading a movement to legislate the registration of all clinical trials.
But also over the past 30 years in the United States, there has been an increase of the use of psychotropic drugs and rates of diagnosed anxiety disorder, mood disorder, childhood bipolar disorder, autism, and ADD. All of which has sharply increased in recent years. Dr. Allen Frances argues that ADD diagnosis used to be “3 to 3.5%. Now it’s 10%. And 4% of kids in American schools are getting medication”. Equally worrying, a recent Canadian study found that the most accurate ADD predictors was a child’s birthday. This is believed to be one side-effect of the DSM known as ‘diagnostic inflation’. The term used to describe the over diagnosis of mental health, which cheapens the value of psychiatric diagnosis.
So to allude back to the hoax story, under the current climate of diagnostic inflation and the growing need to find odd quirks to categorise, can ‘selfies’ ever be viewed as a mental disorder? With all things considered, my answer to this is “probably”. Under current criteria of the DSM-V, excessive use of selfies that deviate from social norms and/or diminish the quality of life can be categorised alongside compensatory narcissism, addiction, or other forms of personality disorder.
“Once the genie is out of the bottle and the book [DSM] is published, people can use it in their own way, which may be radically different from what you intended”, adds Dr. Frances.
Such critique in recent years has shed new light on what we can do in order to improve diagnoses, given that psychiatry suffers from the noticeable absence of biological tests. Mental well-being leans on subjective judgement, which often falls prey to unpredictable change. But in a perfect world, mental illness would only ever be diagnosed through objective and unambiguous tests.
With this, we mustn't rely on erroneous and outdated methods of categorising from the old generation of psychiatrists, some whom have even insisted in including melancholia in the DSM-V. Which is somewhat reminiscent of a Hippocratic system. It is therefore up to the new generation of researchers, clinicians, and educators to develop a new system of mental health classification that isn't constrained by previous progress, and doesn't under-treat in order to avoid misdiagnosis. How this will be achieved will remain to be seen.
Written by Ash Chetri. This piece was originally submitted as part of The Wellcome Trust Science Writing Prize 2014.