What’s Wrong? Diagnosing Diagnoses

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IN VIRGINIA WOOLF’S Mrs. Dalloway (1925), Septimus Smith jumps to his death rather than put himself in the hands of a one-diagnosis/treatment-fits-all psychiatrist, who plans on committing Smith, who has paranoid delusions, to an institution.

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Since the first DSM (Diagnostic and Statistical Manual) appeared in 1952, each subsequent edition has sprouted new diagnoses and sub-diagnoses—with the current DSM-V listing close to 200, compared with six disorders listed in the initial mid-19th-century census of mental patients.

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Binge eating, once considered a “sin,” appears in DSM-V, along with hoarding disorder, premenstrual dysphoric disorder, restless legs syndrome and REM sleep behavior disorder.

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Among those who blame “diagnostic inflation” for turning everyday emotions into medical problems in need of drug treatment is psychiatrist Allen Frances, emeritus professor at Duke University, who chaired the DSM-IV Task Force.

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“ ‘Normal’ badly needs saving,” Frances writes in his book Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life.

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On the other hand, the more narrow and specific the diagnosis, the greater the relief for many sufferers and family members: If only Septimus and his wife had known about shell-shock.

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For Massachusetts science writer J.H., her son’s bipolar 2 diagnosis (BP-II) reassured them both that he was “less bipolar, with mania not over the top but depression that can be difficult,” she said. And that diagnosis led to a crucial treatment decision, because the medication typically prescribed for depression alone could send him into full-blown mania.

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“The main difference between bipolar 1 and bipolar 2 disorders,” according to a Healthline post, lies in the severity of the manic episodes . . . a person with bipolar 1 will experience a full manic episode, while a person with bipolar 2 will experience only a hypomanic episode (a period that’s less severe than a full manic episode).

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What Frances calls “false epidemics of mental disorder” have led to “an excessive proportion of people” relying on drugs. When ADHD was added to the DSM-IV, he writes, the predicted increase in cases was 15%—but rates tripled once drug company ads began selling the diagnosis.

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The increasing popularity of diagnoses such as ADHD can also affect clinicians’ judgments, making them “quick to notice” difficulties associated with ADHD, writes New York City psychiatrist Grant H. Brenner. It also, he says, can cause clinicians to fail to recognize other issues, such as bipolar disorder, that are associated with many of the same symptoms as ADHD.

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Another epidemic, according to Frances, is social phobia, which “has turned everyday shyness into the third most common mental disorder with rates ranging from 7 to a ridiculous 13%” —making the diagnosis another prime target for drug advertising.

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Here too, though, personal experience undermines the criticisms. With her daughter’s diagnosis of social phobia, one Delaware mom could better accept her daughter’s depression, which began with an increasing inability to leave the house—as well as what she always viewed as debilitating shyness, which could be now be relieved with therapy and medication.

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Frances describes two conundrums: how to decide which disorders to include in the diagnostic manual; and how to decide whether a given individual has a mental disorder. In the past, too many sick people were being missed, which made increased sensitivity an early goal of the DSM—but the resulting proliferation in diagnoses now includes too many people.

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Another aspect of the controversy is increasing focus on the “biological model” of mental illness, which according to the past director of the National Institute of Mental Health (NIMH), Thomas Insel, makes these conditions no different from heart disease and diabetes and can be helpful for both clinicians and patients.

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“The only difference here is that the organ of interest is the brain instead of the heart or pancreas,” Insel said, noting that all chronic diseases have behavioral as well as biological components.

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To better predict medication response and illness course—but not to replace the DSM—NIMH has created its own classification system based on brain imaging, genetics, cognitive science and other research (called Research Domain Criteria, RDoC).

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For 13-year-old Sasha Egger, intense and sudden paranoia that was traced to an autoimmune attack, subsided immediately after an infusion of antibodies, writes Moises Velasquez-Manoff in the Atlantic. “Scientists have found that simply activating people’s immune systems as though they were fighting a viral infection can cause profound despair and suicidal thoughts.”

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But critics of the biological approach say too much attention on this model can overlook behavioral and emotional changes that occur with mental illness, according to New York psychiatrist Jerome Wakefield—and has led to the decline in patients’ receiving psychotherapy for depression while rates of antidepressant use have stayed the same.

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As for BP-II, the total number of bipolar diagnoses has doubled since its addition to the DSM, Frances notes, because “there is no clear boundary between hypomania and simply feeling good.” But he acknowledges that “perhaps the most important diagnosis [determining whether the patient has bipolar mood swings or “unipolar” depression] in all of psychiatry is unfortunately the most difficult.”

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Mood-stabilizing medications prescribed for bipolar disorder come with side effects that include “dangerous weight gain, diabetes and heart disease,” according to Frances. But anti-depressants can send BP-II patients into classic manic episodes that include “spending money like a drunken sailor and being intrusively sexual.”

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Awareness of hypomania could have saved Delaware theater director A.J., who was given Prozac for depression—and her subsequent mania when traveling in Israel led to involuntary hospitalization.

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In her case, though, an even narrower, more specific description was also helpful. Although never listed in the DSM, Jerusalem Syndrome describes a religious-themed psychotic break experienced by about 50 tourists a year: Believing she was pregnant with Baby Jesus (she was not pregnant), A.J. refused to budge from her place at a holy shrine.

—Mary Carpenter

Every Tuesday, well-being editor Mary Carpenter reports on health news you can use.