Andrew Sullivan is concerned that the new DSM-V psychiatric classification system will define the 40% of college students who sometimes binge drink as alcoholic. He links to an angry critique by Russell Blackford, who sees the potential over-extension of the alcoholic label as misguided and oppressive.
As I outlined a few days ago, and Dr. Deni Carise elaborates on today at Huffington Post, the alarming 40% figure that keeps being quoted is misleading. If criteria were broadened, the purpose would be specifically to identify problem drinkers who are not what is commonly understood as alcoholic. Deni writes:
…never fear, the new DSM will not cause more people to be diagnosed with addiction. Instead, more people who may not yet be addicted (but whose drug use is nonetheless problematic and unhealthy) will be able to access very inexpensive but proven effective treatment earlier and easier. Treating these folks is no different from treating those in the early stages of diabetes — it requires minimal professional help, some education, and simple lifestyle changes. We wouldn’t wait until a pre-diabetic started experiencing the symptoms of full-blown diabetes before we offered him or her help. Instead, we would intervene early in hopes of preventing such a difficult future. The same should apply for those with early substance misuse.
In short there is no chance that the new DSM will lump together unhealthy drinkers with people who have drunk very heavily for years and are now physically dependent (what we commonly think of as “alcoholics”). So if that worry is keeping you awake at night, roll over and sleep the sleep of the just.
This reality isn’t germane to Blackford’s other criticism, which is that by labeling certain patterns of drinking as unhealthy, medicine is inappropriately condemning particular lifestyles. I have heard this argument many times before. It rests on the false assumption that a statistical relationship is equivalent to a moral judgment imposed by outsiders.
A typical debate of this sort runs roughly as follows. An epidemiologist gets up at a conference and says that people who drink at level X have, say, twice as much chance of dying in a car accident than people who drink at level Y. Then someone in the audience says “My friends and I drink like that. We all have jobs and are responsible parents, how dare you call the way we drink risky! Who are you, doctor, to decide that my drinking is wrong?”.
But the people who decide that level X of drinking raises risk of an auto accident aren’t epidemiologists or any other elite professionals. Rather, the statistical relationship between the behavior and risk is set in the most democratic way imaginable: Tens of millions of people drink and then decide whether or not drive and then some of them have accidents and some don’t. The epidemiologist just counts the ballots.
The truth value of a statistical relationship between drinking (or any other behaviour) and bad outcomes is thus independent of whether anyone feels judged by it. Plenty of doctors drink in a risky fashion and may not like the relationship between heavy drinking and bad outcomes either. But it just doesn’t matter what those doctors (or anyone else) wish were true; the relationship between unhealthy drinking and bad outcomes reflects what millions of drinkers have actually done and the collective consequences of their behaviour.
Thank you, thank you, thank you! Statistics are population measures, although the outcomes are individual. When someone like me points out an odds ratio, or a substantive correlation we are talking about what happens to large numbers of people. No moral judgements attach.
Wait- I’m confused. I thought an alcoholic was someone who drinks more than his doctor.
This is a tempest in a teapot. I’ve been a licensed psychologist since the 1980’s, and I’ve seen it all. Let me be blunt about this. Clinicians don’t care that much about diagnosis. Sometimes they pretend they care, because it makes them sound erudite. In reality no one cares, because diagnosis in mental health is different from diagnosis in the rest of medicine.
Beginning with DSM-III, psychiatric diagnoses were set up as a set of symptoms. To be diagnosed with major depression for example you must have 5 symptoms out of a larger set of 9. It sounds very scientific, but unlike medical diagnoses, there are no underlying conditions related to it and there are no unique treatments to a specific diagnosis.
The two current rages in the field, SSRI’s (a type of antidepressant medication) and cognitive behavior therapy, are used to treat a number of diagnoses, including, depression, anxiety, panic disorder, obsessive-compulsive disorder, and a bunch of others. If I use the same treatment for four or more diagnoses, what difference does the diagnosis make?
So, DSM-V definitions may affect research, but they won’t affect practice. It doesn’t matter how broad the definition is. Clinicians will use it if they feel it’s justified. To use the example of alcoholism, which is the DSM-V debate du jour, how does alcoholism get diagnosed? In the real world, an alcoholic is someone whose drinking causes problems, either for themselves or someone else. That’s it.
If John gets drunk and crashes his car, he’ll be diagnosed with alcoholism. No insurance company is going to object, either. If they don’t think the treatment is helping, they may cut the treatment short, but they won’t object to the diagnosis.
All this means for us clinicians is that we’ll have to learn some new names for old problems. Feh!
But the problem is once you get a diagnosis, enhanced by the the clinician not caring as Joe experienced, the diagnosis “takes a life of its own”, the words of Dr. Allen Frances, chair of DSM-1V explains, in a mea culpa lecture, May 6th lecture ‘The Overdiagnosis of Mental Illness’. Inflationary diagnosisis Francis says, more often than not, results in ineffective or counter productive treatment or therapy, sometimes for years. The mislabelling or ‘overdiagnosis’ of mental illnesses takes just as long a time to reverse, as the´’uncaring’ clinician took a short time, normally in about a ten minute interview to initially make the ‘overdiagnosis’ and then provide the prescription drugs, often with very damaging side effects such as gaining weight for those patients who had mild or moderate conditions or worse, no conditions but had false positives on DSM questionnaires.
Actually, I don’t think overdiagnosis is much of a problem, especially on an outpatient basis. It may become more of a problem when we have full integration of the electronic health record.
Now, a patient walks into a doctor’s office and says, “I’ve had all these diagnoses and (a) none of them have helped me, or (b) this is what helped me the most.” If it’s (b), you start there. If it’s (a) you sort through all the different “symptoms,” until you come up with your own ideas.
If a person is being treated “for years” without improvement, then a good clinician should evaluate whether the person is simply chronic and unable to improve more, or needs changes in medication or psychotherapy. But that’s not a diagnostic problem; it’s a case management problem.
By the way, Thomas Szasz’s book “The Myth of Mental Illness” is very old, but still relevant to this discussion of diagnosis.
“never fear, the new DSM will not cause more people to be diagnosed with addiction. Instead, more people who may not yet be addicted (but whose drug use is nonetheless problematic and unhealthy) will be able to access very inexpensive but proven effective treatment earlier and easier. ”
Never fear, standardized tests won’t be used to stigmatize or punish students or teachers. Instead, administrators will be able to identify students in need of improvement at an early stage in their careers and target intervention resources much more accurately than before.
Yeah, I don’t know what planet many of you live on, but if you don’t think that our society uses “medical” diagnoses like these as a basis for moral judgments, then you haven’t being paying attention.
Worse than this, however, is the fact that the diagnoses themselves are partly moral in nature, while masquerading as naturalistic. If people didn’t have moral problems with drinking/drug use, then it wouldn’t be a subject of social-scientific investigation in the first place. And this is one of the dirty little secrets of so much social science; something which is difficult to detect, unless someone has had significant education in philosophy of science-namely, that many if not most of the categories of behavior studied by social scientists are not natural kinds, but rather the result of social and moral construction.
The Allen Frances video mentioned above is must-watching and devastating to boot. It demonstrates not only how un-scientific so much of contemporary psychology/psychiatry is, but how much of a threat it is to the social standing/civil liberties of an enormous number of people.
==Dan Kaufman