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Under new psychiatric guidebook we might all be labelled mad

“We are all mad here” explains the Cat to Alice when she wonders about the strangeness of Wonderland. Well, life is starting to follow art. If people make the mistake of following DSM-5, the new diagnostic…

Medication misuse is out of control in the US and more psychiatric labelling in DSM-5 will not help. Whale05/Flikr

“We are all mad here” explains the Cat to Alice when she wonders about the strangeness of Wonderland. Well, life is starting to follow art. If people make the mistake of following DSM-5, the new diagnostic manual in psychiatry that was published on Saturday, pretty soon all of us may be labelled mad.

When I worked on the taskforce for DSM-4, we were very concerned about taming diagnostic inflation - but we only partly succeeded. Then four years ago, I became aware of the excessive enthusiasm around all the new diagnoses being proposed for DSM-5, including many that were untested. I hate to rain on anyone’s parade, but I knew this would be disastrous for the millions of people who were likely to be mislabelled, stigmatised and given excessive treatment.

In the US, the “sick” are distinguished from the “well” by the diagnostic and statistical manuals developed by the American Psychiatric Association.

The problem is that definitions of mental disorders are already written too loosely and are applied much too carelessly by clinicians, especially by the GPs who do most of the prescribing of psychiatric drugs.

And things are about to get much worse. Under DSM-5 diagnostic inflation looks set to become hyperinflation and will lead to an even greater glut of unnecessary medication. I would qualify for a bunch of the new labels myself – and you might too.

The grief I felt when my wife died would now be called “major depressive disorder”; forgetfulness in older age “mild neurocognitive disorder”; my gluttony now “binge eating disorder”; and my hyperactivity “attention deficit disorder”. As for my twin grandsons' temper tantrums, this could be misunderstood as “disruptive mood dysregulation disorder”. And if you have cancer and your doctor thinks you are too worried about it, there’s “somatic symptom disorder.” It goes on, but you get the idea.

About half of Americans already qualify for a mental disorder at some point in their lives and the rates keep skyrocketing, especially among kids. In the past 20 years, the prevalence of autism has increased, childhood bipolar has multiplied 40-fold and attention deficit disorder has tripled.

One consolation: the kids are not suddenly getting much sicker – human nature is pretty stable. But the way we label symptoms follows fickle fashions, changing quickly and arbitrarily. And freely giving out inaccurate diagnoses can lead to grave harms – medication that isn’t needed, stigma, lower self confidence and reduced self expectation.

There are also downstream effects. Many parents were panicked about the alarming rise in rates of autism and fell for the disproven belief that it was caused by vaccination. Trying to avoid a false epidemic of autism caused by nothing more than changed labelling meant they stopped vaccinating their kids and exposed them to the very real measles outbreak that recently occurred.

And medication use is out of control – 20% of Americans regularly use a psychotropic drug; 10% of teenage boys are taking a stimulant for ADHD; 25% of our active duty troops report abuse of a prescribed med; and the US has more deaths from prescription drug overdoses than from street drugs.

In the UK you are protected against the worst effects of diagnostic and drug exuberance. Doctors use ICD-10, the classifications compiled by the World Health Organisation, not DSM-5; they follow prudent guidelines from Nice, which sets the standards for health treatment in the UK; the British-based Cochrane group emphasises evidence-based medicine; GPs do less prescribing; and drug companies exert much less power and cannot advertise directly to consumers as they do in the US.

But the measles outbreak and ADHD rates prove the UK is not out of the woods. Bad ideas from America sometimes have much more influence than they deserve.

My advice is to be an informed consumer. Never accept a diagnosis or a medication after a cursory evaluation. A psychiatric diagnosis can be a turning point in your life – as important as choosing a spouse or a house. Done well, it can lead to life-improving treatment; done poorly it can lead to an inaccurate label and a harmful treatment.

People who have mild and transient symptoms don’t need a diagnosis or treatment. The likelihood is they are visiting the doctor on one of their worst days and will get better on their own. Medication is essential for severe psychiatric problems but does more harm than good for the worries and disappointments of everyday life. Better to trust time, resilience, support and stress reduction.

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17 Comments sorted by

  1. Alex Cannara

    logged in via LinkedIn

    "Under new psychiatric guidebook we might all be labelled mad " --

    It's hard to type while guffawing! A good laugh is always welcome, even at a funeral.

    We need no guidebook to determine that we're almost all "mad" -- just look around at the world.

    And, imagine the world we're leaving our descendents -- they also will need no manual to determine our madness.

  2. Yoron Hamber


    Thanks Allen, my thoughts too. It doesn't really matter if you're a psychoanalyst or psychiatrist, one still need to 'see' ones patient, and give oneself the time to listen. Not use some book to label them. In a world where advertising rules, although differently depending on if you're a 'end consumer' or a 'distributor' as a doctor might be seen as, we all need to use common sense. Unlucky the end result might be that you, the 'consumer', must become the informed party, on good and bad. For some…

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  3. Janeen Harris


    Guidelines are one thing, but it should not dictate to a professional. Why would a mental health professional put their knowledge and common sense in their back pocket so they can mindlessly tick boxes and then shove their patients into those boxes? It happens far too often in all the fields that need to be people focused.

    1. Sue Ieraci

      Public hospital clinician

      In reply to Janeen Harris

      The thing that's missing from this discussion, though, is that a person isn't diagnosed with an illness just because of some tick boxes - they have to be suffering distress or be unable to function, and seeking medical help.

      To those of us who are happily and functionally living our lives, perhaps doing strange things but generally not threatening the safety of others, unless we seek psychiatric assistance for our own suffering, we won't have to interface with the DSM at all.

    2. Peter Ormonde
      Peter Ormonde is a Friend of The Conversation.


      In reply to Sue Ieraci

      Depends a bit Ms Sue.

      You know the sort of parents I'm thinking of ... little Tristram or Efegenia isn't rocketting through pre-school as expected - maybe it's ADHD, or depression - increasingly widespread amongst four year olds. DSMV and DSMIV before it - perhaps any sort of DSM approach - sanctions the "medicalisation" of childhood, adolescence, grief, having a rotten bully of a boss ...

      And it should. Where these phases or circumstances cause a reasonable person distress and stop them…

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    3. Sue Ieraci

      Public hospital clinician

      In reply to Peter Ormonde

      I follow your reasoning, Mr O, but I think the reality might be something different.

      It is highly unlikely that a school child would be prescribed a psychoactive medication on the basis of a seven minute chat. If it happened, it should be complained about and appropriate consequences suffered by the prescriber.

      Child psychiatry is highly specialised - I have never heard of a child being medicated purely on the basis of one short GP consultation and a few tick-boxes. Have you?

    4. Peter Ormonde
      Peter Ormonde is a Friend of The Conversation.


      In reply to Sue Ieraci

      Yes - but who would believe anything uttered by parents who would name their defective heirs Tristram and Efegenia? - certainly not me. Seemed to be in a heck of a hurry to get a diagnosis and the comforting re-assurances of a "condition" and pills and so forth. Like some sort of scout badge.

      Very much doubt that every child diagnosed with ADHD sees a psychiatrist. I'd have a dreadful feeling that the overwhelming majority are reliant on a GP. Same with depression and anxiety and other "mood…

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    5. Peter Ormonde
      Peter Ormonde is a Friend of The Conversation.


      In reply to Peter Ormonde

      PS... Here's the latest advice from NSW Health

      Page ten is the one you're chasing ... GPs in the bush - which reflects my experience.

      Page 11 is also excellent - sets out the criteria for giving dexy to ADHD cases younger than two! I wonder who they ask for evidence of uncontrollable conduct? Eeeek!

  4. Peter Ormonde
    Peter Ormonde is a Friend of The Conversation.


    Only half!!!

    My understanding of the DSM approach suggests that it was in part driven by a repudiation of what was regarded as the "unscientific" and speculative approaches of the talking cure and therapy. It was also necessary under the US system for a specific diagnosis in order to attract insurance payments, and of course in the court system where diminished responsibility was increasingly used as a defence or mitigating factor.

    This was the period of One Flew Over the Cuckoo's Nest…

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  5. charles davies

    Quizzical Observer

    Does cognitive dissonance /religious faith rate a mention ?
    With a lot of the world suffering under that disorder I'm pretty sure that an effective treatment is urgently required, and just imagine ----?
    (John Lennon -1940-1980)

  6. Meg Thornton


    This article speaks to one of my concerns with the DSM-V - namely, while it demonstrates a lot of work put into labelling and defining "abnormality", there hasn't been the same level of effort put into defining what's "normal". In many ways, the DSM-V seems to be doing for mental health what the fashion and beauty industries do for physical health - it narrows the acceptable parameters for judging health status down to a few indicators, and then sets the target for "normality" somewhere unreachable by the majority of the population.

    Then, as in the case with our physical health standards, whole industries step in to sell us the story that their product will be the one to "save us" from our abnormality, or "correct" our (industry-defined) problems.

    The DSM goes to a lot of trouble figuring out what counts as "abnormal" - but have the creators of this tome gone to an equivalent amount of trouble figuring out what counts as "normal"?

  7. Leo Kerr


    you gotta hand it to the creative genius of Big Pharma - we're all mad and we all need a pill .... I suppose if you look at how we're burning our home down they may be right after all.

  8. Evelyn Haskins


    I think most people ARE mad!
    (Especially, probably the politicians.)

    It is us sane people who need medication to survive!

  9. Peter Hindrup


    Commonly heard when, and where I grew up was: " we are all mad, only some are worse than others'.

    There undoubtedly those who are very ill with mental problems who need all the help they can get.

    Back in the early 60's I got a letter from my father saying hat he was in a psychiatric hospital, and he expected that I would think it he ought to have been there years ago. Sounded a lot like Dad!

    Up to the hospital to see him, as he talked of the farm, lambing figures, all the usual, and his…

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  10. Timothy Kilroy


    "But the way we label symptoms follows fickle fashions, changing quickly and arbitrarily."

    I entirely agree, there is now a large net to be cast upon us to catch out peculiarities and label us as insane. Whats more disturbing is that information sourced to make the DSM are from the world's leaders in the various fields of mental illness's!

    While I do have time for the very REAL illness's such as PTSD, OCD, Schizophrenia, Alzheimer's just to name a few, I do not however have time for the illness's…

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  11. Sue Ieraci

    Public hospital clinician

    If the new DSM has done nothing else, it has created a wealth of traffic for TC! Can't be all bad!