Psychiatry in the News
The medicalization of emotional life
Posted June 6, 2013
Towards the end of May, the American Psychiatric Association published its fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This long awaited update of the of the DSM (colloquially referred to by some as the “Bible of Psychiatry”) has been the focus of considerable prepublication controversy among mental health professionals and in the popular media. Previous editions of the DSM have also received some degree of media attention. But DSM-5 has raised the intensity of the controversy to unprecedented heights, in part because of the widely publicized criticisms of psychiatry insiders including Allan Frances (the chair of the task force that developed DSM-IV) and Robert Spitzer (who chaired the DSM-III task force).
Criticisms of DSM-5 are similar in nature (if not intensity) to those which were leveled at both DSM-IV and DSM-III. For example, claims for the degree of reliability of diagnostic categories are exaggerated, evidence regarding the validity of the diagnostic categories is limited, and feelings that are inevitable aspects of the human condition (e.g., sadness, mourning, anxiety) are increasingly viewed as symptoms of mental illness to be treated with medication. An important aspect of the criticism is directed at the rapidly accelerating tendency to overprescribe medications for emotional distress with dubious effectiveness and potentially serious side effects. A more fundamental criticism of DSM-5 (also leveled at the previous two editions of the DSM) is directed at the disease model of psychiatry, which views emotional problems as similar in nature to physical illnesses such as tuberculosis, heart disease, or cancer. Critics are also concerned about the potential for stigmatization of everyday problems in living.
While DSM-5 has received widespread media attention, many people are not aware of important policy changes currently taking place at the National Institute of Mental Health (NIMH), the largest source of government funding for research on mental health problems and their treatment. Thomas Insel, the Director of NIMH has recently announced that NIMH is abandoning the DSM as an organizing framework for guiding funding priorities. He acknowledges that unlike existing taxonomies within medicine, which have been derived from systematic empirical research, DSM diagnoses are based on task force consensus about clusters of clinical symptoms rather than research. Because of this concern, NIMH has held a series of workshops over the past year and a half, in order to develop a new nosology that will be used to establish funding priorities for all future research. This framework, known as the Research Domain Criteria (RDoc), is intended as the starting point for the development of a new diagnostic system (to replace the DSM) that will be grounded in the empirical evidence that emerges out of future research guided by the RDoc system.
Since the publication of DSM-III in 1980, NIMH has prioritized the funding of research that investigates specific treatment approaches targeted at groups of patients who fit into specific DSM categories (e.g., major depression disorder, generalized anxiety disorder, panic disorder). Many researchers and clinicians believe that that this limits the relevance of research to real word clinical practice, since few patients seeking treatment fit neatly into one diagnostic category. Moreover, different patients with the same DSM diagnosis can be heterogeneous in many important respects. One of the implications of the recent shift in NIMH policy is that the door will be opened to funding research evaluating the effectiveness of more flexible treatment approaches that are potentially more applicable to patients in real world clinical practice. So far so good. There is, however, an important catch. The National Institute of Mental Health's new policy initiative also makes it unequivocally clear that the fundamental assumption guiding future funding priorities is that the bedrock level of analysis is biological in nature.
As Thomas Insel stated in a recent interview reported in the May 7, 2013 issue of The New York Times: The goal of RDoC is to “reshape the direction of psychiatric research to focus on biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms." This is a perpetuation and expansion of a trend which has been taking place at NIMH for many years now, that privileges the biological over all other levels of analysis (e.g., psychological, emotional, social). It is one thing to hypothesize that psychological and emotional problems are associated with changes at the biological level (e.g., specific patterns of brain activity or levels of neurotransmitters) or that symptom remission is associated with biological changes. It’s another to assume that the underlying causes of mental health problems are always biological in nature and that meaningful improvements in treatment will only take place when we can directly target the relevant brain circuitry. While it may be the case that biological factors play a more significant causal role in some mental health problems (e.g., schizophrenia) than others, the assumption that the major causal factor for mental health problems is always biological is a form of simplistic reductionism.
I want to be perfectly clear that I do not question the potential value of brain science research. What I do question is the single-minded emphasis on brain science research to the virtual exclusion of all other forms of mental health research. The new NIMH paradigm for research means that the amount of funding available for the development and refinement of treatments such as psychotherapy that are not targeted directly at the brain circuitry (although they do influence it indirectly), is likely to continue to shrink. It is important to recognize that funding priorities shape the programs of research pursued by scientists, and thus the type of research findings that are published in professional journals and disseminated to the public. This in turn shapes the curricula in psychiatry and clinical psychology training programs, which shapes the way in which mental health professionals understand and treat mental health problems. It also influences healthcare policy decisions and the type of coverage provided by third party insurers.
In concrete terms, the explicit NIMH policy shift is likely to mean that despite the large and growing body of evidence demonstrating that a variety of forms of psychotherapy (e.g., cognitive therapy, interpersonal psychotherapy, psychoanalytic therapy, emotion focused therapy) are effective treatments for a range of problems, we are likely to continue to see a decreasing availability of the already diminishing resources that can provide high quality psychotherapy for those who can potentially benefit from it.