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Psychiatric labels and kids: benefits, side-effects and confusion

MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition. As a child and adolescent psychiatrist…

As an adolescent and child psychiatrist, I dispense all sorts of labels – but what do they mean? emildom

MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition.


As a child and adolescent psychiatrist my daily work involves diagnosing children and young people with various mental disorders. There are diagnostic manuals to guide me: the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the mental disorders section of the the International Classification of Diseases of the World Health Organisation, 10th Edition (ICD-10).

These manuals give algorithms and criteria by which diagnoses can be made. Since its third edition in 1980, the DSM has mostly followed the “medical model” of diagnosing by checking off lists of symptoms with little reference to past or present life stressors or the person’s coping or personality style. And ICD-10 followed the same post-DSM-III model.

Thus I dispense labels such as ADHD (attention-deficit hyperactivity disorder) for mainly boys with hyperactive or inattentive behaviour; if they’re particularly naughty they get the label ODD (oppositional defiant disorder) and if they’re being seriously nasty then CD (conduct disorder).

With troubled teenagers who are down in the dumps with disturbances of appetite, sleep, loss of interest in life then MDD (major depressive disorder) or if it’s less severe, dysthymia may apply.

Nervous children may get a number of overlapping anxiety labels – OCD (obsessive compulsive disorder), panic disorder, GAD (generalised anxiety disorder), social phobia, separation anxiety disorder, or a number of other labels.

Some disorders such as anorexia nervosa or bipolar I disorder (once called manic-depressive psychosis) define more discrete and serious mental illness. But others such as bipolar II disorder (with milder manic symptoms), and all the NOS (not otherwise specified) disorders can blur with other labels.

Although schizophrenia is a very serious illness, transient psychotic symptoms are very common, even among the so-called normal young people who are under significant stress and of course under the influence of drugs.

Every few years an epidemic sweeps the nation’s schoolyards. In the mid-1990s it was ADHD; a few years ago an American epidemic of so-called PBD (pediatric bipolar disorder) touched a few here. Since then it seems a plague of Asperger’s disorder or ASD (autistic spectrum disorder) has struck many.

The DSM-5, due out next year, is likely to unleash a new epidemicDMDD (disruptive mood dysregulation disorder), which has been strongly criticised by the former DSM-IV task force head Professor Allen Frances.

Child psychiatry is not a cookbook discipline of simplistic labels with drugs ready for each label. theloushe

The question is what do the labels mean? They are rarely complete explanations in themselves; they label surface symptoms but not underlying causes.

Labels are useful in research where simplification is necessary. In clinical practice they sometimes are useful too, but almost as often they can distract or obscure the real issues rather than point to the right treatment options.

In psychiatric training, we learn that what really counts is a biopsychosocial (biological, psychological and social) formulation. This is a few paragraphs which accompanies the diagnosis, summarising the main relationships, genetic inheritance, stressful events, temperament and psychological coping style of the person. The biopsychosocial formulation seeks to uncover and put in perspective all the causes of their symptoms and point to what help is needed, even if not readily available.

Child psychiatry is not a cookbook discipline of simplistic labels with drugs ready for each label on some shelf. At worst, DSM labels totally obscure the real underlying causes by making everyone think they have an answer. University of Adelaide psychiatry professor Jon Jureidini has referred to such use of diagnostic labels to explain people’s predicaments as “unexplanations”.

This sentiment has been echoed elsewhere in the profession. In an address to the Royal Australian and New Zealand College of Psychiatrists, University of Sydney Professor of Psychiatry Philip Boyce commented:

“The current paradigm seems to be that if a patient suffers from a specific DSM disorder, then there is a specific medication for this. If that medication does not work, try some other medication… a number of trends have contributed to this: increased service demand, the deification of DSM, the influence of the pharmaceutical industry, a misunderstanding of evidence-based medicine (EBM), managerialism and the influence of consumerism. … The (simplistic) DSM approach is exemplified by …treating DSM disorders rather than individuals.”

Oxford Professor Andrew Scull summed the issue up in a Lancet article ) where he described the DSM-III as “an anti-intellectual system published in book form: a check-list approach to psychiatric diagnosis and treatment” by which “Patients and their families learned to attribute mental illness to faulty brain biochemistry”.

To be fair, three DSM diagnoses do relate to stress and trauma:

  • RAD (reactive attachment disorder) in young children due to highly disturbed relationships with their primary caregivers;
  • PTSD (post-traumatic stress disorder) but criteria are restricted to mainly life threatening events; and
  • Adjustment disorder, where someone has more trouble than usual coping with a serious stress.

But stress weaves in through everyone’s life. In particular, complex childhood trauma and long-term outcomes of attachment problems are under-represented in the DSM.

One remedy would be the inclusion of DTD (developmental trauma disorder) into the DSM-5. But DTD seems to have lacked sufficient support in the APA’s DSM-5 committee. Most child psychiatrists find this a grave pity as DTD would add increased focus on the ongoing need for good child protection services.

In the end I’m glad my daily work involves broader, deeper and more commonsense thinking than simply dispensing diagnostic labels.

Taking the time to engage with young people, their families, and sometimes school counsellors and others, to explore and understand all the interacting causes and meanings of the troubling symptoms is rewarding. And it’s often successful, as natural healing mechanisms are unleashed when real causes are addressed.

This is the sixth part of our series Matters of the Mind. To read the other instalments, follow the links below:

Part one: Explainer: what is the DSM and how are mental disorders diagnosed?

Part two: Forget talking, just fill a script: how modern psychiatry lost its mind

Part three: Strange or just plain weird? Cultural variation in mental illness

Part four: Don’t pull your hair out over trichotillomania

Part five: When stuff gets in the way of life: hoarding and the DSM-5

Part seven: Redefining autism in the DSM-5

Part eight: Depression, drugs and the DSM: a tale of self-interest and public outrage

Part nine: Why prolonged grief should be listed as a mental disorder)

Part ten: Internet use and the DSM-5’s revival of addiction

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16 Comments sorted by

  1. Flick Grey

    Resource co-ordinator, Our Consumer Place

    Thank you Peter, for this article, and for articulating how diagnoses can shed some light, but often function as "unexplanations" - inhibiting deeper understanding.

    In my own experience, I became adept at hiding my distress as a young person - although of course it leaked out - and did not receive any diagnoses until I was 26, starting with Borderline PD, then Adjustment Disorder, PTSD, depression ... all missing the point that I had suffered developmental trauma and was struggling with the consequences…

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    1. Peter Parry

      Child and adolescent psychiatrist & senior lecturer at University of Queensland

      In reply to Flick Grey

      Thankyou Flick for your very insightful and personal response. I entirely agree.

      The problem is more severe in the USA than here where fortunately our health system is less diagnosis driven and allows therapists to use full biopsychosocial reasoning and psychotherapies. I have read articulate stories from American young adults whose childhoods and adolescences were blighted by erroneous use of antipsychotics with serious side-effects, the effects of labelling on sense of self and the real problems…

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    2. Flick Grey

      Resource co-ordinator, Our Consumer Place

      In reply to Peter Parry

      Hey Peter,

      I understand that we have greater access to psychotherapies in Australia than in America (and yes, I know survivor/consumers in the States suffer terrible consequences of their system being so economically-driven). Let's hope the bean counters in Australia don't send us in that direction!

      Thanks for the head up about Evolve - it's important to recognise the pockets of good work.

      But I disagree that we have reasonable funding for psychotherapies in Australia. I'm heavily engaged…

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  2. john mills
    john mills is a Friend of The Conversation.

    artist

    Thanks for your article Peter, good on you for coming in here to talk as a psychiatrist, feels a bit like the dentist add on the telly,except for a small change, this is Peter, we cant hear the words of a psychiatrists, because we cant show you his head. Peter the thing that worries me is that sometimes we waylay concern in a compassionate, mature and empathetic caring way, in order to alleviate the concern and down play the concern like we do when a kid falls over and cuts their knee, or when a…

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  3. david menkes

    associate professor

    hey Peter. Nicely put. It seems to me that diagnosis often reflects a collusion between doctors and patients who, for somewhat different reasons, seek labels and their implied explanations of what's going on. This is sometimes useful, but often not, as you indicate. The real decider, for me, isn't so much whether the label is valid (pathophysiologically or otherwise) but whether it serves a useful purpose in optimising functional outcome, quality of life, etc. Labeling is thus a fine art, and needs to be calibrated to the needs of the patient, not those of the doctor, institution, or drug company...

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  4. Niall McLaren

    Psychiatrist

    "...what really counts," says Dr Parry, "is a biopsychosocial (biological, psychological and social) formulation.' In 1998, I showed that the so-called Biopsychosocial (BPS) model, approach, stance etc did not exist. This did not slow down psychiatry: for years, the RANZCP appealed to this model as its justificationi (and Canadian psychiatry still does). In 2004, I said "Yet all along, we have known, or ought to have known, that there is no such model, thereby exposing ourselves to charges of intellectual…

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    1. john mills
      john mills is a Friend of The Conversation.

      artist

      In reply to Niall McLaren

      An excellent post Niall, Like Abraham said, "You can fool some of the people all of the time, and all of the people some of the time, but you can not fool all of the people all of the time" I really hope you do live to see the great day. I really hope we all live to see it. Although i think it might need to be a series of great days for some reason, Feels close though. :).

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    2. Julie Roccisano

      logged in via email @hotmail.com

      In reply to Niall McLaren

      Well put Niall. I was very surprised to read that you are a psychiatrist and you strongly question aspects of your profession. Often people try and protect their profession from criticism. Good on you!

      I would really love to see an overhaul of many parts of the current system. Perhaps in 30 years time we will look back and have the same sense of revulsion as reading 'One Flew Over the Cuckoo's Nest' provokes today.

      As a counsellor working from a client-centred and empowerment perspective I have the happy privlege of being a part of positive change.

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    3. Emma Anderson

      Artist and Science Junkie

      In reply to Niall McLaren

      The thing is though, acknowledging that biology, psychology and social variables are intimately entwined makes sense. The problem is, as I think Niall was trying to say (I'm not clear on this) is that orthodox psychiatry isn't actually using that model.

      It's taught in psychology degrees routinely. It's common sense. There is a basis for it. However, it's not actually used routinely in clinics, or in univariate research designs, and that's part of the problem.

      Back to the DTD classification…

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    4. Emma Anderson

      Artist and Science Junkie

      In reply to Emma Anderson

      Addendum [to my little rant]:

      Another side of the coin is that kids who were abused may wind up as what is commonly called the target patient at any age.

      That is, understandable reactions to trauma (avoiding triggers, issues with trust, mood fluctuations, etc) are pathologised. Meanwhile, the abuser/s are over somewhere else, probably abusing someone else, because their behavior is not being treated.

      The abuse is pathological, but the victims are pathologised more often than the abusers. That is not only grossly unfair to the victim, but it is creating more victims.

      It doesn't change that victims of abuse need help and sometimes lots of it. But, if you want to prevent abuse, go after the abusers.

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    5. Peter Parry

      Child and adolescent psychiatrist & senior lecturer at University of Queensland

      In reply to Emma Anderson

      Thanks for your insightful comments Emma.

      I'm not really sure what Niall is suggesting by seeming to dismiss the biopsychosocial model - except that it is not used enough in a more sophisticated manner - a manner that you indicate Emma in your first post.

      Many colleagues in child psychiatry that I know are frustrated that DTD didn't make it past the American Psychiatric Association's DSM-5 committee. Most of my colleagues also practice the biopsychosocial approach and recognise trauma and…

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    6. Emma Anderson

      Artist and Science Junkie

      In reply to Peter Parry

      "Many, if not most, conditions and symptoms represent a somewhat arbitrarily defined pathological excess of normal behaviors and cognitive processes"

      I think it's a bit rich (perhaps arbitrary is the correct word) to define what is pathologically excessive when one is presented with a extraordinary life event that precedes what a person who has not experienced that event would categorise as an excessive reaction.

      For example, war. Hands up if you've actually been in a war zone. My hands…

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    7. Peter Parry

      Child and adolescent psychiatrist & senior lecturer at University of Queensland

      In reply to Emma Anderson

      Emma, You may be interested in the book "The Loss of Sadness: How psychiatry transformed normal sorrow into depressive disorder." http://www.amazon.com/Loss-Sadness-Psychiatry-Transformed-Depressive/dp/0195313046

      Nonetheless it is important that we all can receive help and well-trained professional help for distressing symptoms/reactions, even where those symptoms/reactions are perfectly understandable. Good wise friends do a lot of unpaid psychotherapy. There is good evidence emerging that…

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  5. john mills
    john mills is a Friend of The Conversation.

    artist

    What is needed is a (mental health psychiatric treatment) rehab withdrawal center, run by psychologists and counselors, independent of a psychiatrists sick seeing imagination, and force drugging regime, or practices, or and, sick seeing mentality. A cognitive based therapy center, with all the different non invasive therapies, and health/care practices, that people actually desire, want. If they dont work, then hand them back to the oppressors, at least they will know that they probably actually…

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  6. john mills
    john mills is a Friend of The Conversation.

    artist

    some of the titles that the withdrawal center will need to apply to their clients are,

    post traumatic psychiatric abusive treatment disorder
    post traumatic psychotropic substance disorder
    post traumatic mental health facility disorder
    post traumatic incarceration environment disorder
    post traumatic psychiatric/mental health facility/ family separation disorder
    post traumatic ***electrocution*** disorder
    post traumatic psychotropic alienation disorder.

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  7. Niall McLaren

    Psychiatrist

    Emma Anderson and a psychiatrist, Peter Parry, argue against the extreme reductionism of mainstream biological psychiatry. Anderson says “...acknowledging that biology, psychology and social variables are intimately entwined makes sense... orthodox psychiatry isn't actually using that model. It's taught in psychology degrees routinely. (biopsychosocial model) is common sense.” Parry says “Most of my colleagues also practice the biopsychosocial approach..”
    What they fail to understand is that reductionist…

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