What's A Mental Disorder? Even Experts Can't Agree

This article is from NPR's “All Things Considered.”

What's A Mental Disorder? Even Experts Can't Agree
by ALIX SPIEGEL

The American Psychiatric Association's Diagnostic and Statistical Manual, or DSM, updated roughly every 15 years, has detailed descriptions of all the mental disorders officially recognized by psychiatry. It's used by psychiatrists, insurance companies, drug researchers, the courts and even schools.

But it's not without controversy: The proposed changes suggested this year have sparked a kind of civil war within psychiatry.

In a small condo on the beach in San Diego lives Allen Frances, who blames himself for what he calls the "Epidemic of Asperger's." Frances edited the last edition of the DSM, and he's also the new DSM's most prominent critic.

As one with a graduate degree in “Rhetoric: Scientific and Technical Communication” I am aware of the complex nature of the DSM editorial process. Though I specialize in language education and autism, I have spent a fair amount of time researching how “autism” is defined by clinicians, researchers, educators, and the general public. There is less consistency than one might imagine.

This NPR report first addresses the perverse incentives some parents encounter in public schools. As Grinker reported in Unstrange Minds, parents do “shop” for diagnoses when they know a child needs additional supports. What the individual diagnosis is matters less to parents than what services are provided by a school.

Surprising Incentives

It's not that Frances doesn't think that Asperger's exists and is a real problem for some people; he does. But he also believes the diagnosis is now radically overused in a way that he and his colleagues never intended. And why, in his view, did Asperger's explode? Primarily, Frances says, because schools created a strange unintentional incentive.

"In order to get specialized services, often one-to-one education, a child must have a diagnosis of Asperger's or some other autistic disorder," he says.

"And so kids who previously might have been considered on the boundary, eccentric, socially shy, but bright and doing well in school would mainstream [into] regular classes," Frances says. "Now if they get the diagnosis of Asperger's disorder, [they] get into a special program where they may get $50,000 a year worth of educational services."

I admit to witnessing this firsthand as an educator and advocate. I have met parents who shopped, taking a child to three or even four clinicians until the “right” diagnosis of “autism spectrum disorder” was finally official. Though it is rare, it does bother me. If two or three psychiatrists or educational psychologists refuse to offer the desired diagnosis, maybe it isn't the right diagnosis. It troubles me that parents in some school districts share lists of the experts most likely to offer an official diagnosis with the least effort.

To combat such diagnoses, the DSM must be precise so it can be universally and rigidly applied during initial screenings. When you offer a broad definition, using criteria such as “social impairment,” each clinician will have a subjective idea of what constitutes an impairment. Qualifiers such as “significant” impairment are no better, since that is also subjective.

"Anticipate the worst. If something can be misused, it will be misused," Frances says. "If diagnosis can lead to overdiagnosis and overtreatment, that will happen. So you need to be very, very cautious in making changes that may open the door for a flood of fad diagnoses."

As far as Frances is concerned, the new DSM is proposing too many diagnoses that are written in too broad a way, meaning that ultimately a huge number of new people will be categorized as mentally ill.

We can only wait until 2013 to know the final DSM criteria for various mental health conditions. At that time, the arguments will become even more heated.

The final draft of the DSM-5 won't be published until 2013. In the meantime, people like Allen Frances will agitate for the number of diagnoses and their scope to be reduced. And the small group of people in charge will face the difficult question of what to put in — and what to leave out.