Crazy Like Us: How the U.S. Exports Its Models of Illness
The fears of many European psychiatrists may soon be realized. Earlier this week, Psychiatric News reported that the American Psychiatric Association has begun petitioning the various agencies overseeing changes to the ICD, or International Classification of Diseases, to request that they adopt its most-controversial changes in DSM-5.
According to Psychiatric News, the APA has asked the ICD formally to include seven new disorders listed in DSM-5, though not in ICD-9-CM or ICD-10-CM. They include Binge-eating disorder, Disruptive mood dysregulation disorder, Social (pragmatic) communication disorder, Hoarding disorder, Excoriation (skin picking) disorder, and Premenstrual dysphoric disorder, whose controversial history is relayed here. Additionally, the APA requested that ICD-10-CM include gender dysphoria in adolescents and adults, rather than the more-recently listed gender identity disorder, as the organization has “revised its conceptualization and terminology” of the problem defined.
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The APA’s aim is clearly to make the two diagnostic systems converge more successfully, to ensure greater consistency—and avoid an apples and oranges problem—in psychiatric research. But the outcome, if the petition is approved, is likely eventually to export to Europe and other regions a range of disorders still mired in controversy and, according to the results of the APA’s own field trials, still very much in need of further research.
Last November, it should be noted, Psychiatric News reported that of the APA’s own field trials for DSM-5, nine out of 23 adult or child diagnoses, generated under real-world conditions, showed “questionable” to “unacceptable” diagnostic reliability. The criteria, according to the report, were tested from October 2010 to February 2012 by 279 clinicians at 11 academic centers in the United States and Canada. Additionally, despite reclassifying as “very good” results that DSM-IV field trials would have recorded as merely “okay” and despite failing to carry out a crucial second round of tests to determine the number of likely false positives or misdiagnoses resulting from their new proposals, the vice chair, chair, and members of the DSM-5 task force reluctantly conceded: “evidence from the literature indicates that the current diagnostic criteria for a number of mental disorders are unclear.”
Despite such worrying ambiguity in the very research used to frame and define the new additions, the APA apparently now feels ready to urge the ICD and the huge population it represents to include the same disorders for approval. With a suggestion that the ICD might even adopt the imprecise and highly controversial Illness anxiety disorder and Somatic symptom disorder, while giving diagnostic codes for both the presence (294.11 [F02.81]) and absence (294.10 [F02.80]) of behavioral disturbances, APA Director of Research Darrel Regier flatly contradicted his organization’s earlier announcement about its field trials when announcing of the recent petition, “For these conditions, there is no question about meeting the criteria for a major neurocognitive disorder and the need for intervention if behavioral disturbances are present.”
At such moments, it may be helpful to recall that Disruptive mood dysregulation began life as “Temper dysregulation disorder,” a trial balloon floated “to address concerns about potential over-diagnosis and overtreatment of bipolar disorder in children.” The problem, introduced by the APA’s earlier DSM-IV, stemmed from its committees defining Bipolar II Disorder without needing signs of mania, a decision that helped contribute to an unprecedented forty-fold increase in diagnoses. Until the proposal to add “Temper dysregulation disorder” attracted worldwide concern, ridicule, and disbelief, including because its focus on “severe recurrent temper outbursts in response to common stressors” could easily pathologize children’s tantrums and meltdowns, the DSM-5 Task Force (offering no explanation or rationale for the replacement) decided a new name but the same criteria would work just as well instead. That’s now the same disorder it wants to persuade Europe and other regions using the ICD to adopt.
Earlier this year, in an article called “Why DSM-5 Concerns European Psychiatrists,” Paris-based psychiatrist Patrick Landman noted, “the DSM has led to a growing medicalization of emotions, whereby the distinctions between normality, its variations, and its pathologies have all but disappeared.”
The manual, he continued, “has also caused an inflation in psychiatric diagnoses that are both clinically and scientifically questionable and that include ‘catch-all’ categories or chimeras that are the source of artificial epidemics, with the result that psychotropic drugs are increasingly prescribed to children, in turn leading to secondary effects such as obesity, heart disease, addiction or overdose, traffic accidents, loss of inhibition, violent acts, etc.—leaving aside the numerous psychological, family-related and social effects, such as the stigma or exclusion caused by mistakenly labeling a person with a psychiatric diagnosis, in the case of false positives.” He warned, “The DSM’s conception of psychiatric diagnosis as a fixed rather than evolving condition has promoted a confusion between justified prevention and haphazard prediction that may sometimes pose a danger to civil liberties.”
Disruptive mood dysregulation disorder and Premenstrual dysphoric disorder are, to such experts, textbook examples of that confusion. Should the APA fail to get ICD approval for them, it would naturally face charges that the conditions it decided to list as mental disorders were either inaccurate or purely American phenomena, an effect due either to our culture or the organization that publishes its most-influential psychiatric manual.
Clearly, the APA wants to avoid that outcome, to make its definitions seem global rather than parochial or, in some cases, noninevitable. But is the organization using the language of convergence, as Landman and others imply, to arm-twist other diagnostic systems into adopting its own highly controversial changes, to mask their status as such?
In Crazy Like Us, his compelling account of “the Globalization of the American Psyche,” Ethan Watters suggested as much. Like Landman, he voiced concern that well-meaning but mistaken Western psychiatrists have helped to export inaccurate, sometimes bogus conceptions of mental illness. The result, he claimed from meticulous fieldwork, is closer to medicalization—and banalization—than a helpful collation of knowledge and understanding. “We are flattening the landscape of the human psyche,” he warned. “We are engaged in the grand project of Americanizing the world’s understanding of the human mind.”
Prof. Christopher Lane
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