Psychiatry & Psychology - It's all about interaction.
I'm asking if there are prevailing theories about mental health and mental illness that come into conflict with material in the DSM-IV TR, or if the manual is widely accepted by the mental health community.
I'm in my third year in a psychology degree, and for every disorder we are learning the psychology of, we also get the DSM IV, and ICD-10. But yes, I agree, it is known that the DSM IV-TR is what is most used for diagnosis, though they give us the ICD too because this is sometimes used. In terms of manuals, from the disorders I have looked at (not PTSD yet), the ICD tends to be more vague than the DSM IV-TR. But there is not disagreement as such between these two manuels.
However, I would like to say - The Diagnostic and Statistical Manual, is in actual practice, not statistical! Decisions are made my committees of Psychiatrists - with no statistical basis to it! The 'experts' get together and decide what should go into the DSM, and can only be influenced by research, not decided by research. The Anti psychiatry movement has an issue with this...
There is, however, some opposition to the DSM, in terms of models and psychiatry in general. The DSM operates on a Biogegenic approach, a 'disease-based' medical model - Moncrieff (a psychiatrist who researches) states in her 2007 article (published in
The Psychologist) that psychiatry's foundation is that "mental distress and deviant behaviour arise from biological abnormalities, and that biological abnormalities can resolve them". Moncrieff included, there are plenty of theorists out there who disagree with this approach to psychological disorders. The advantages of the medical model however, are that it allows thinking about mental 'illness' in terms of a medical/biochemical problem and can thus be treated as such, and there are improvements for people suffering with the treatments developed. Another advantage is it encourages the classification of disorders....
However there are questions and debate around how valid the medical model is, and if mental illness truly exists in the way it is percieved. A popular opposition to the DSM, and biogenic approach are those belonging to the anti-psychiatry movement which began in the 1950's by psychiatrists such as Lang, Cooper and Esterson, and the most radical critic of all, Szasz (he wrote 'The Myth of Mental Illness'). They suggested society was the problem, not the person.
They argue 'mental illness' is a moral not medical/organic problem. For example, Heather (1976) argues some illnesses like neuroses and personality disorders lack any organic cause. Moncrieff (2007) argues that "there is no convincing evidence that people grouped according to psychiatric diagnoses have distinct underlying pathological profiles." She goes on to use Schizophrenia as an example, outlining the medical evidence for the pathological differences, and then stating that these abnormalities are neither universal nor specific, as similar abnormalities are found in PTSD. Moncrieff 2007 cites Nemeroff et al., 2005 for this finding (As a personal query, perhaps this is why some PTSD sufferers 'hear' the voices of their abusers?). She also cites Irle, et al (2005) to have found such abnormalities also existing in personality disorders, and then Lin et al. (2005) finding these abnormalities also in depression. In her article, she states that "early findings of abnormalities of dopamine receptors in people with schizophrenia turned out to be related to exposure to antipsychotic drugs"! In her own research, she finds that recent research that does suggest elevations of dopamine in some untreated psychotic patients did not include patients with other diagnoses, nor control for other factors known to increase dopamine activity (Moncrieff, 2007). She states the case for depression is similar also. She goes on to talk about how psychiatric drugs are not specific to categories of, or specific disorders either, and that studies have failed to confirm the specific drugs to work better than non-specific ones, and that "in fact, the effects of the drug may not even be specific to the mentally ill. According to the disease centred model, drugs should only exert their effects in an abnormal nervous system. Yet studies with non-depressed human volunteers show that drugs induce characteristic states that are consistent with patients' descriptions and side-effect profiles".
Back to the 1950's anti-psychiatry movement - Szasz argued if a mental illness has a physical cause (like deterioration of the brian, nervous system, or homonal/chemical imbalance) it should be called a disease of the brain or neurophysiological disorder and treated medically, not mentally. If no physical origin exists, it is not illness but a 'problem of living'.
Good outcomes of the anti-medical model have come about as a result of this... there is now more tolerance of unusual behaviour (rather than everyone being placed into asylums), safe houses, treatment in the community now exists. Psychiatry did move with the criticisms of the anti-medical model in terms of 'chemical imbalance' also.
These days, the arguments now surround this kind of thinking in that is there really 'chemical imbalance' or not, and what causes this chemical imbalance- life, or is it purely organic (as Moncrieff researches and discusses above)? The anti-psychiatry movement still exists, and still argues against other aspects of psychiatry. At the present moment, the anti psychiatry movement is a loose collection of groups arguing against psychiatry aspects. In the UK there is
'The Critical Psychiatry Network' but there are plenty of anti-psychiatry groups globally. A lot of the emphasis of this movement has been in it's argument against psychiatric drugs, like the SSRI debate.
The movement also has issues with diagnosis in itself. The DSM operates differently in terms of general medicine in that it's only role is signs and symptoms. The manuel does not look at cause medically at all. It is purely descriptive and based on 'symptoms' that are presented, rather than physical changes as symptoms. There is no disorder in the DSM which states 'change in serotonin/dopamine/monamine levels' for example. The DSM relies only on symptoms presented that are not physiological... thus it is quite obvious how easy it is to misdiagnose considering psychiatry is founded upon biological abnormalities....!
Additionally, diagnoses are troublesome if not handled carefully in overall treatment with the patient, because it runs a high risk of 'removing responsibility' from the sufferer. This then opens up a whole new debate, often found in courts... what consitutes somebody to be able to claim 'not guilty by reason of insanity'. Could we say ALL mental illness could suggest this? I won't get into this debate here, or this post will go off topic, but you get my drift...
In terms of PTSD, as Anthony has said, the ONLY way of 100% diagnosis of PTSD is through brain imaging. But there is no diagnostic physical test to my knowledge of any mental disorder, rather research suggests that there are brain differences. This is not included in the diagnostics in the manuel itself. This is where the DSM is not 'The be all and end all' and psychiatry does not (or should not) simply diagnose based on that one book, as more and more factors are being discovered around causes of 'presenting symptoms'. The purpose of the DSM is a guide for psychiatrists to help in diagnosis, although one usually would not be diagnosed unless their symptoms presented matched the criteria. But other factors should always be considered outside of the manuel based on the psychiatrist's expertise (hence why we don't all get given the DSM to diagnose ourselves with - there is more to it than that). But the DSM, and concept of diagnosing mental disorders has problems - if we don't know the cause, how can we diagnose something? How do we decide what cut-off should exist? Like plenty have a number of PTSD symptoms, but not all - and thus are not diagnosed with PTSD, misdiagnosed with something else - or not diagnosed at all! This is criminal in some ways - because these people are denied help and treatment based on classification a group of psychiatrists sitting around a table decide on.
This is another issue with the DSM that receives criticism and argument for. In terms of PTSD, an evolutionary psychologist Cantor calls for re-thinking of how it is classfied (in his 2005 book). He believes PTSD is a FEAR based disorder, NOT an ANXIETY disorder. One example he gave was that a person may suffer anxiety when, for example walking down a dark alley when they had been attacked in an alley. But the difference between anxiety and PTSD, is that someone with PTSD would on instinct 'fight, freeze or flee'....or avoid altogether in order to fit with the PTSD symptoms of classification. This is a fear reaction, not an anxiety reaction. The difference is subtle, but important. Again this is down to defintion issues... if something is not accurately defined, it cannot be accurately researched. As a result, he believes a lot of people are being diagnosed with PTSD, because it is in the anxiety disorder category, when they have an issue with anxiety and NOT PTSD. As a result, he believes, as fight/flight and freeze are evolutionary built in survival reactions, evolution has an important role in aiding the understanding of PTSD in that it is adaptation gone wrong, as opposed to 'disease'.
Additionally, diagnosis is really a 'shortcut' for professionals to quickly understand the issues of the patient so as treatments can be developed and given. Someone goes to a psychologist and says "I am diagnosed with PTSD", and straight away the psychologists knows the symptoms and issues this person is suffering... and the associated psychological treatments around PTSD.
What is good, and very interesting is that in terms of PTSD being recognised in the DSM IV, this is really something brilliant in psychiatry and psychology... this really changes the way psychiatry has viewed 'mental illness', in terms of mentall illness being an underlying chemical imbalance. It now recognises that, yes, there are brain changes that occur in PTSD, and cause PTSD... but that this disorder can ONLY be caused by trauma. It incorporates szasz's statement to mean something new .... PTSD has physical changes/differences, but it can only be caused through 'the problem of living'....essentially, PTSD can only be caused by trauma. This is really quite revolutionary because PTSD as a disorder in itself clearly brings psychiatry and psychology together. It does not fit strictly into a 'disease-model' based on medical and physiological causes alone. It is all about interaction...
I am not sure if this is properly checked out or anything, but I found a video on Utube about 'Psychiatry: The Industry of Death', talking about the damage the 'psychiatric system' has caused. It states "Nearly twice as many Americans have died in psychiatric govenment hospitals, than in ALL US wars since 1776." Now that, if it is a true stastistic... that is terrifying. Having said that, I don't know how many lives have been saved by drugs that HAVE worked for the mentally ill to compare this to. Psychiatry, psychology, and science has a long way to go before reaching perfection and true understanding... if this is at all possible. But debates like this, controversial groups like the anti psychiatry movement, and those pro-psychiatry is what will push science forward to trying to achieve a better understanding.
In my opinion, our understanding of mental health is still in its infancy... much like the days when we were debating whether or not micro organisms were created from reproduction or spontaneous generation.
Have to say, I think I agree based on everything I have written above and learned about all of this.
