Psychiatric Bible : Bringing Order to Disorders

Do you have trouble falling asleep at night? Staying awake in the daytime? Do you sweat too much? Are you hooked on caffeine or tobacco?

Do you have irresistible urges to seduce strangers on the street or colleagues at work? Do your children have inexplicable difficulties in school with math or reading? Have you ever felt an uncontrollable need to tear your hair out?

If you or a loved one has ever experienced any of these symptoms, you can now rest easy: American psychiatry has a name and number for your problem.

Hair tearing is trichotillomania (312.39). Addiction to caffeine is caffeinism (305.90). Problems with math or reading are developmental disorders (315.10, 315.00). Excessive seductiveness is a symptom of histronic personality disorder (301.50). And so on.

The Standard Guide

These new labels--and more--can be found in “The Diagnostic and Statistical Manual of Mental Disorders, Third Edition--Revised,” America’s standard psychiatric diagnostic reference guide.

First published by the American Psychiatric Assn. in 1952, the then-slim pamphlet contained fewer than 60 psychiatric disorders. Today, the DSM-III-R, as it is called, is a voluminous 567-page text describing the symptoms, although not the cause or treatment, of more than 250 mental problems, ranging from emotional upsets to retardation. It is the guide, the bible of mental illness used not only by psychiatrists but also by psychologists and other mental health clinicians as well.

The addition of so many new diagnoses is not necessarily a sign that Americans are more disturbed than they once were, but it is an indication that experts over the years have expanded their definition of mental disturbance and become far more precise in describing symptoms, said Gerald Davison, chairman of the psychology department at USC and author of numerous books and articles on abnormal behavior.

Surrounded by Controversy

The very existence of such a book would seem to suggest that there is agreement in the field about what is mental illness and what is not. But, in fact, the DSM is surrounded by controversy, reflecting not only the rift between psychiatry and its sister discipline, psychology, but also of the chronic problem of trying to apply exact terms to inexact and changing symptoms, said Theodore Millon, a professor at the University of Miami, Coral Gables, who edited a 1986 book on the history and future of the DSM.

The dilemma is reflected simultaneously in the avalanche of new theories of mental illness over the last three decades and the deletion of some of the most revered diagnoses of mental illness.

Among them was one of the hallmarks of mental illness, neurosis. In its place are any of a number of more precise and detailed categories, from separation anxiety disorder to sleepwalking disorder, said Dr. Robert L. Spitzer, professor of psychiatry at Columbia University College of Physicians and Surgeons in New York and one of the principal drafters of the two major revisions of DSM in the last decade.

The guide also includes dozens of personality disorders, mood disorders, sexual disorders, impulse-control disorders.

In general, many psychologists and psychiatrists agree, the more detailed descriptions of symptoms and the increased number of diagnoses have been a boon to clinicians and researchers who can now be certain that when they talk of a certain form of mental illness they are using a common language, whether they are experts in the field or novices, whether they live in New York or in Nebraska.

What’s more, as a result of better diagnoses, there can often be better treatments.

Thanks to the DSM, a person who suffers repeated unprovoked attacks of terror, for example, can now be diagnosed as having a form of panic disorder for which there are a variety of drugs and counseling therapies that offer some relief, if not a cure. In the past, however, similar symptoms might well have gone undiagnosed or been badly misdiagnosed as schizophrenia or heart attack, the treatments for which would have been wholly inappropriate, according to “Treatment of Mental Disorders,” a text edited by Spitzer and Drs. John H. Griest and James W. Jefferson of the University of Wisconsin Medical School.

Sharp Criticism, Debate

It is not surprising, however, in a field as divided and controversial as the mental health industry, that many of the changes have been subject to sharp criticism and considerable debate. And beginning this fall, there are likely to be even more disputes as various committees of the American Psychiatric Assn. set to work drafting the next version of the diagnostic manual, DSM-IV, slated for publication in the early 1990s.

The outcome of these debates will have consequences reaching far beyond the psychiatric community, predicted Millon, who is one of a handful of psychologists participating in the DSM-IV revision along with psychiatrists.

In recent years, for example, the manual has come to be used not only by mental health clinicians and researchers but also by insurance companies in determining who should be reimbursed for treatment and by courts in ruling on who should be held legally responsible for criminal actions, Millon said.

Some of the controversies have had a decidedly political ring to them.

Homosexuality, for example, had been designated in the DSM as a form of mental illness for years until the late 1960s when gay organizations launched a major lobbying campaign against the APA. In a 1980 edition of the book, homosexuality was removed from the list of mental illnesses but then only partially. People who were homosexual but wish they weren’t were still regarded as mentally disturbed, under the DSM-III. It was not until 1987, when the DSM-III-R went into effect, that all references to homosexuality as a mental condition were finally erased.

Spitzer, who oversaw those and other changes in the third volume, said in a recent telephone interview that the elimination of homosexuality from the list was made not so much because of political pressure but because a growing body of research had begun to show that “there were not significantly more signs of psychopathology associated with gays” as was thought to be the case before 1970.

Decisions about what should be included in the manual and what should be excluded are based on scientific research and clinical experience, although, Spitzer himself acknowledged, there are instances when there simply isn’t enough information.

One such case involves another politically charged diagnosis. It is listed in the DSM under the rather abstruse label of late luteal dysphoric disorder but is popularly known as premenstrual syndrome, referring to a variety of physical and emotional changes associated with specific phases of the menstrual cycle.

Many psychologists and a few psychiatrists, particularly women psychiatrists, strongly objected to the inclusion of such a category in the DSM because, in the words of Lenora Walker, a Denver psychologist, it inappropriately labeled as mental illness what is “clearly a gynecological disorder.”

The Power of Labels

And, given the power of labels, particularly labels that categorize someone as mentally ill, the question of whether or not to use this diagnosis is more than just an academic issue or matter of an intellectual curiosity, said Hanna Lerman, a Los Angeles psychologist and author of “A Mote in Freud’s Eye,” a book on feminist psychotherapy.

Two other diagnoses have been equally distasteful to feminist clinicians and have, along with the controversial dysphoric disorder, led to rancorous public debates, the creation of a national lobbying organization called the Coalition Against Ms. Diagnosis and even threats of a lawsuit against the APA.

One of the offending diagnoses is self-defeating personality disorder, used mainly to describe women who are chronically abused and do not remove themselves from the situation. The other is sadistic personality disorder, referring most often to rapists or men who are in some other way dangerously aggressive or abusive.

Essentially, women were being dealt a one-two punch, said Walker, who specializes in the treatment of women. First they are abused. Then they are labeled as mentally ill for allowing themselves to be in an abusive relationship. Finally, their abusers are given a legally acceptable mental defense--sadistic personality disorder--for their actions.

Critics Not Appeased

The names of these controversial disorders were changed several times but even that did not appease the critics. As a result, when the final edition of DSM-III-R finally appeared in print last year, the three controversial diagnoses had been pulled from the main text and placed in an appendix entitled “Proposed Diagnostic Categories Needing Further Study.”

But the debates over these and other issued are far from settled.

So disgruntled are many psychologists with the DSM that the American Psychology Assn. issued an advisory last year warning its members not to use the psychiatrists’ controversial sexual diagnoses.

And several months ago, the psychology organization also began work on what it calls an “alternative diagnostic manual.”

But even some of its own members are skeptical that the psychological association has the substantial financial resources that will be required to complete its project. However, Gary Vanden Bos, one of the directors at the Washington-based association, contends the first stages of research are well under way and that the whole project should be completed at about the same time that the psychiatrists complete the DSM-IV.

The key feature of the psychologists’ manual, Vanden Bos said, will be its brevity in comparison to the DSM. It will probably have, he said, a quarter the number of entries: “Only those (diagnoses) that are reliable and usable . . . and for which there is reasonable scientific support will be included for use by the professional community.”

Clash of 2 Disciplines

Many psychologists have been wondering aloud, for instance, what place learning problems or cigarette smoking or gambling have in a psychiatric text. In the words of one critic, “Clearly many of these problems are quite real, but they could more appropriately be classified as bad habits, socially offensive behaviors, education problems or medical problems outside the realm of psychiatry.”

Such disagreements within the mental health profession come as no surprise given the general skepticism that many psychologists and psychiatrists seem to have about one other’s work. Although the two disciplines often overlap and, more often than not, have similar goals and theoretical underpinnings, their approaches to education and research often differ widely.

Explained USC’s Davison, “Psychiatrists are trained as MDs and, like most physicians, are typically focused on the treatment of individual patients. . . , (whereas) psychologists, (who hold MAs or Ph.D.s) tend, like their counterparts in biology or physics, to be much more concerned with research on large populations of patients.”

When it comes to diagnosing patients, however, U.S. psychiatrists are also at odds with their counterparts in other parts of the world.

For years, the DSM has been in competition with another diagnostic manual, the International Code of Diseases, a compendium of physical as well as mental disorders published by the World Health Organization.

Currently in its ninth edition, the ICD is also now being rewritten and scheduled for publication at just about the time the DSM-IV will appear in print.

Officials in both organizations say that serious efforts are being made to bring the two systems into alignment, although they also acknowledge that longstanding cultural differences and international politicking may limit the possibility of doing away with all differences, at least in the foreseeable future.

As it now stands, according to Spitzer, the American system has nearly 100 disorders not recognized by the international system. Among them: factitious disorders (in which patients feign symptoms or compulsively try to injure themselves), multiple personality disorder (in which one person assumes all of the characteristics of two or more completely different personalities), and narcissistic personality disorder (in which patients show signs of grandiosity, hypersensitivity to criticism and lack of empathy for others).

Whether these are mental disorders that are uniquely American in character or simply diagnoses that are unique to the thinking of American psychiatrists is not in all cases fully understood, Spitzer said.

Determining the nature of mental illness is a very tricky matter, as the experts involved in these projects have found.

Even the term mental “illness” offends some experts in the field, particularly psychologists who prefer to think of mental problems as examples of maladaptive or abnormal behaviors rather than as diseases.

In a well-known book published in the early 1970s, “The Myth of Mental Illness,” Dr. Thomas S. Szasz, a New York psychiatrist, contended just that.

“Psychiatrists,” Szasz argued, “are not concerned with mental illness and their treatments. In actual practice they deal with personal, social, and ethical problems in living.”

By using a “medical model” for diagnosing mental disorders, the American psychiatric community has embraced a very old notion, dating back to the 19th Century when a Germany psychiatrist, Emil Kraepelin (1856-1926), first proposed such a system, said Dr. Gerald L. Klerman of Cornell University’s Department of Psychiatry in a recent book on the upcoming revision of DSM.

“There are too many cases when it simply doesn’t make sense . . . when it does the patient an injustice,” argued Walker, the psychologist from Denver. Take the abused wife who acts cold and mistrustful toward her husband. Is she mentally ill or is she in fact reacting normally to a dangerous, even life-threatening situation? Consider the South African black who has all the medical symptoms of being paranoid. Is he mentally ill or is he, too, reacting normally to a painful and frightening human situation?

Evolution of Treatments

How patients are diagnosed clearly affects the way they are treated. But that has not always been the case, according to Philip A. Berger, professor of psychiatry at Stanford University.

Thirty years ago, precise diagnosis of mental illness did not make nearly as much difference as it does today simply because there were so few forms of treatment from which to choose, Berger explained in a recent article on the history of mental disease.

For years, he said, the principal approach of reputable clinicians was either to hospitalize severely debilitated psychotic patients or to follow Sigmund Freud’s techniques of psychoanalysis with those who suffered from various neuroses. In fact, Freudian theories were such a dominant part of American psychiatry in the 1950s and early ‘60s that the first two editions of the DSM were devoted almost solely to neuroses and psychoses, which were Freud’s nomenclature of mental illnesses.

Today, many patients are still “talked” through their problems. Yet, increasingly since the 1960s with the advent of new pharmaceuticals and basic research into the underlying biochemical causes of some forms of mental illness, traditional Freudian psychoanalysis has given way to a variety of other theories of the causes and treatments for mental illness. These include drug therapies, which try to alter hormonal or chemical imbalances, and new forms of behavioral and cognitive therapies, which try to refocus patients’ thinking and redirect their behavior without necessarily delving into their early lives.

New Set of Problems

But with so many options to choose from, the mental health field has in effect taken on a new set of problems, said Klerman in his book on the DSM.

“The contemporary United States mental health field is characterized by competing schools--biological, social, interpersonal, psychodynamic, and behavioral--each of which has proposed different theories concerning the nature and origin of mental illnesses and emphasized various modes of treatment. . . .

“For many years,” Klerman continued, “there appeared to be no way out of this unsatisfactory situation. . . .

“In the past two decades (with the revisions of the DSM) this situation has changed dramatically,” he said.

The challenge for future DSM revisions will be--more than simply reaching agreement on the names of specific disorders--to prove which approach works best for which disease--a process well under way in some areas of psychiatry and badly lacking in others, according to Spitzer and his colleagues who edited one of the standard texts on the treatment of mental disorders.

It will be at that point, said Larry Beutler, a psychologist in the department of psychiatry at the University of Arizona’s Health Sciences Center, that the mental health profession will genuinely transform “the art” of clinical psychology and psychiatry into “a true science.”