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Revisions to Psychiatry's 'Bible' Have People Crying Overmedication -- But Don't Freak Out Just Yet

For what might strike a lot of people as inside baseball, the debate over the upcoming edition of the Diagnostic and Statistical Manual of Mental Disorders is garnering a lot of media attention.
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For what might strike a lot of people as inside baseball, the debate over the upcoming edition of the Diagnostic and Statistical Manual of Mental Disorders is garnering a lot of media attention.

Reports on the controversial revision, due out in 2013 from the American Psychiatric Association, crop up with regularity, pretty much each time new proposed changes are made public. Lately, the reports have focused on the what a Salon contributor called a "full-scale revolt" on the part of British and American counseling associations, who fear expanded diagnoses will lead to overmedication.

I've explained before that I think the term "overmedication" is a misnomer, because the people who employ it tend to do so without explaining what would constitute an appropriate level of medication. Unfortunately, when journalists and mental health professionals write about the DSM debate, they tend not only to use "overmedication" unquestioningly, but to treat it as an inevitable outcome of the impending revision. That helps get people to care about an otherwise rather abstruse controversy, but it also relies on some questionable leaps of logic.

Because the new manual loosens diagnostic criteria for certain disorders and adds additional conditions to the list of pathologies, critics worry that more people being diagnosed with existing disorders, while others will qualify for diagnoses that presumably would not have merited a label under the old system.

By extension, it would seem, more people will be treated with medication, because that tends to be how we treat psychiatric disorders in America. Indeed, a growing list of DSM diagnoses in recent decades has roughly coincided with increasing numbers of people taking psychiatric meds. But as scientists are fond of pointing out, correlation is not causation.

This line of reasoning is also problematic because it tends to assume that mental health professionals will blindly follow whatever the DSM says. The book is called the "bible" of psychiatry because it is the lingua franca of psychiatric diagnosis, but that doesn't mean it's taken as gospel by everyone who uses it.

In fact, therapists' so-called revolt against the proposed revisions demonstrates this point. The therapists are not protesting because they think the existing manual is perfect and ought not be changed. They applaud the attempt to resolve certain problems with the current DSM, but are concerned that the proposed revisions will magnify existing tendencies to pathologize ordinary emotions and behavior, especially in certain vulnerable populations, such as the elderly, children and teens.

As such critiques demonstrate, many -- perhaps even most -- doctors and mental health professionals already harbor considerable skepticism about the DSM diagnostic system, which categorizes patients' problems based on checklists of symptoms and tends to disregard social and psychological factors. But they buy into the system because they want to be paid, and insurance companies, government agencies and the like typically require a diagnosis for reimbursement.

Clinicians tend to view diagnoses as means to an end, not as voice-of-God pronouncements of absolute truth. That's also true in the case of medication. As the diagnosis is based on symptoms, so, too, is treatment. Even the experts don't definitively understand the underlying causes of mental illness, the best they can do is treat the symptoms.

Often -- perhaps too often -- that involves medication. In many cases, however, mental health professionals are not so much worried about the generic "overmedication" mentioned in media accounts as they are about certain new diagnoses, such as "Attenuated Psychosis Syndrome" and "Disruptive Mood Dysregulation Disorder" leading to certain heavy-duty medications -- namely, atypical antipsychotics -- being prescribed to particular groups, such as young people.

Such concerns are well-founded. But in many situations, including those relating to other contested diagnoses, such as attention deficit/hyperactivity disorder and generalized anxiety disorder, doctors are much more likely, I think, to base their prescribing decisions on the degree of existing dysfunction rather than whether or not a patient technically qualifies for a given diagnosis.

I've witnessed this repeatedly as both a patient and a journalist. In more than a dozen years of seeing various general practitioners, psychiatrists and therapists, I've had many diagnoses assigned to me, none with much conviction.

Invariably, when I've inquired about which condition I "have," clinicians tell me not to worry about the actual diagnosis, that the label is a formality and the relevant thing is identifying the troubling symptoms and minimizing the discomfort they cause me. Yet, just one doctor has ever suggested without prompting that I discontinue or pare down my medication regimen.

Call me overmedicated if you will, but overzealous diagnosis isn't what's driving my pharmacological treatment.

Interviewing young people about their experiences taking psychiatric meds for a book on the topic, I've also been struck by how little stock their prescribing doctors seem to put in their diagnoses. Symptoms frequently change as kids get older, and so, therefore, do diagnoses. In many cases, the people I interviewed weren't even sure what, exactly, their diagnosis was. And they generally didn't justify their need for medication based on the disorder they'd been diagnosed with. Instead, they emphasized the particular symptoms that were troubling them.

And, when those symptoms abated, they often abandoned their medication. Asked why, they didn't declare themselves cured or a particular disorder. Rather, they said that they didn't want to bother with the inconveniences and side effects of meds when their symptoms seemed to have cleared up.

Don't get me wrong: I and many of my interviewees would love to have a doctor enthusiastically embrace a particular diagnosis. It would help give structure, meaning and validation to what we're going through. But the doctors, though often eager to prescribe drugs as treatment, aren't so keen on embracing a particular diagnosis as gospel.

Neither are other mental health professionals. Once, out of curiosity, I looked up the diagnostic code my therapist had recorded on my bill. It was for panic disorder. I asked her why she'd done such a thing -- I haven't had panic attacks since high school. Oh, she replied calmly, she'd listed that as my diagnosis because in her experience insurance companies often covered only "biological" conditions such as panic disorder, not "psychological" ones like generalized anxiety disorder.

"So," I said, "You think I have generalized anxiety disorder?" She demurred. She was skeptical about hard-and-fast definitions. But if I must know, she said, then, yes, probably generalized anxiety better described what I was going through.

None of this, I should note, had any bearing on my prescriptions. The clinician in question was a psychologist, and I saw her for therapy, while a psychiatrist prescribed my meds. The psychiatrist assigned me a different diagnosis altogether. And I only know that because I just looked it up.

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