Saturday, June 15, 2013
The past, present and future of psychiatric diagnosis
Department of Psychiatry, Duke University, Durham, NC, USA
Modern descriptive psychiatry was born two centuries
ago in the classiﬁcation of Pinel, was later systematized in
the textbook of Kraepelin, and was then expanded by Freud
to include outpatient presentations previously seen by neurologists. Brain science also ﬂourished in the second half of
the 19th century and has enjoyed a second revolutionary
advance during the past thirty years. Unfortunately, however, the attempt to explain psychopathology using the remarkable ﬁndings of neuroscience has thus far had no
impact on psychiatric diagnosis or treatment. The crucial
translation from basic science to clinical practice is necessarily even more difﬁcult in psychiatry than in the rest of
medicine, because the human brain is the most complicated thing in the known universe and reveals its secrets
slowly and in small packets.
Psychiatric diagnosis must therefore still rely exclusively on fallible subjective judgments, not on objective biological tests. In the not too distant future, we will ﬁnally
have laboratory methods for diagnosing Alzheimer’s disease, but there is no pipeline of promising tests for any of
the other mental disorders. Biological ﬁndings, however
exciting, have never been robust enough to become testworthy, because the within-group variability always drowns
out the between-group differences. It appears certain that
we will be stuck with descriptive psychiatry far into the
There have been two crises in conﬁdence in descriptive
psychiatry: the ﬁrst was in the early 1970s, the second is
occurring right now with the publication of DSM-5. The
earlier crisis was occasioned by two highly publicized
studies that exposed the inaccuracy of psychiatric diagnosis and threw into serious question the credibility of psychiatric treatment. A landmark study proved that British
and US psychiatrists came to radically different diagnostic
conclusions when viewing videotapes of the same patient
(1). And Rosenhan (2) exploded a bombshell when his
graduate students were kept in psychiatric hospitals for
extended stays after claiming to hear voices, despite the
fact that they behaved completely normally once they
were admitted. Was psychiatry entitled to a place among
medical specialties if its diagnoses were so random and its
treatments so nonspeciﬁc, especially when the other specialties were just then becoming increasingly scientiﬁc?
Psychiatry’s response was dramatic and effective. The
DSM-III, published in 1980, featured detailed deﬁnitions
of mental disorders that, when used properly, achieved reliabilities equivalent to much of medical diagnosis. The
DSM-III soon stimulated its own revolution, quickly transforming psychiatry from research stepchild to research
darling; in most medical schools, the department of psychiatry now ranks behind only internal medicine in research
But psychiatric diagnosis is now facing another serious
crisis of conﬁdence, this time caused by diagnostic inﬂation. The elastic boundaries of psychiatry have been steadily expanding, because there is no bright line separating
the worried well from the mildly mentally disordered.
The DSMs have introduced many new diagnoses that
were no more than severe variants of normal behavior.
Drug companies then ﬂexed their powerful marketing
muscle to sell psychiatric diagnoses by convincing potential patients and prescribers that expectable life problems
were really mental disorders caused by a chemical imbalance and easily curable with an expensive pill.
We are now in the midst of several market-driven diagnostic fads: attention-deﬁcit/hyperactivity disorder (ADHD)
has tripled in rates in the past twenty years; bipolar disorder
has doubled overall, with childhood diagnosis increasing
forty-fold; and rates of autistic disorder have increased by
more than twenty-fold (3). In the US, the yearly prevalence
of a mental disorder is reported at 20–25%, with a 50% lifetime rate (4), and Europe is not far behind (5). A prospective
study of young adults in New Zealand has reported much
higher rates (6) and another of teenagers in the US found an
astounding cumulative 83% rate of mental disorders by age
The expanding concept of mental disorder brings with it
unfortunate unintended consequences. Only about 5% of
the general population has a severe mental disorder; the
additional 15–20% have milder and/or more temporary
conditions that are placebo responsive and often difﬁcult
to distinguish from the expectable problems of everyday
life. Yet an amazing 20% of the US population now takes a
psychotropic drug (8) and psychotropic drugs are star revenue producers – in the US alone $18 billion/year for antipsychotics, $12 billion for antidepressants, and $8 billion
for ADHD drugs (9). And 80% of psychotropic drugs are
prescribed by primary care physicians with little training
and insufﬁcient time to make an accurate diagnosis (10).
There are now more overdoses and deaths from prescribed
drugs than from street drugs.
And the investments in psychiatry are badly misallocated, with excessive diagnosis and treatment for many
mildly ill or essentially normal people (who may be more
harmed than helped by it), and relative neglect of those
with clear psychiatric illness (whose access to care in the
US has been sharply reduced by slashed mental health
budgets) (11). It is no accident that only one third of
111people with severe depression get any mental health care
or that a large percentage of the swollen US prison population consists of psychiatric patients with no place else to
go (12). A recent meta-analysis shows the results of psychiatric treatment to equal or surpass those of most medical specialties (13), but the treatments must be delivered
to those who really need them, not squandered on those
likely to do as well or better on their own.
This disparity between treatment need and treatment
delivery is about to get much worse. The DSM-5 has introduced several new disorders at the fuzzy and populous border with normal and has also loosened requirements for
many of the existing disorders. The biggest problems are
removing the bereavement exclusion for major depressive
disorder, adding a very loosely deﬁned somatic symptom
disorder, reducing the threshold for adult ADHD and posttraumatic stress disorder, adding a diagnosis for temper
tantrums, introducing the concept of behavioral addictions,
combining substance abuse with substance dependence,
and adding mild neurocognitive disorder and binge eating
The DSM-5 has been prepared without adequate consideration of clinical risk/beneﬁt ratios and has not calculated the large economic cost of expanding the reach of
psychiatry. It has been unresponsive to the widespread
professional, public, and press opposition that was based
on the opinion that its changes lacked sufﬁcient scientiﬁc
support and often deﬁed clinical common sense. And
a petition endorsed by ﬁfty mental health associations
for an independent scientiﬁc review, using methods of
evidence based medicine, was ignored.
There will be no sudden paradigm shift replacing descriptive psychiatry with a basic explanatory understanding of the pathogeneses of the different mental disorders.
This will be the gradual and painstaking work of many
decades. In the meantime, we must optimally use the
tools of descriptive psychiatry to ensure reliable and
accurate diagnosis and effective, safe, and necessary
treatment. It is time for a fresh look. The preparation
of the ICD-11 provides an opportunity to re-evaluate
psychiatric diagnosis and to provide cautions against its
1. Kendell RE, Cooper JE, Gourlay AJ et al. Diagnostic criteria of
American and British psychiatrists. Arch Gen Psychiatry 1971;
2. Rosenhan DL. On being sane in insane places. Science 1973;179:
3. Batstra L, Hadders-Algra M, Nieweg EH et al. Child emotional
and behavioral problems: reducing overdiagnosis without risking
undertreatment. Dev Med Child Neurol 2012;54:492-4.
4. Kessler RC, Berglund P, Demler O et al. Lifetime prevalence and
age-of-onset distributions of DSM-IV disorders in the National
Comorbidity Survey Replication. Arch Gen Psychiatry 2005;6:593-
5. de Graaf R, ten Have M, van Gool C et al. Prevalence of mental
disorders and trends from 1996 to 2009. Results from the Netherlands Mental Health Survey and Incidence Study-2. Soc Psychiatry Psychiatr Epidemiol 2012;47:203-13.
6. Mofﬁtt TE, Caspi A, Taylor A et al. How common are common
mental disorders? Evidence that lifetime prevalence rates are
doubled by prospective versus retrospective ascertainment. Psychol Med 2010;40:899-909.
7. Copeland W, Shanahan L, Costello EJ et al. Cumulative prevalence of psychiatric disorders by young adulthood: a prospective
cohort analysis from the Great Smokey Mountains Study. J Am
Acad Child Adolesc Psychiatry 2011;50:252-61.
8. Medco Health Solutions Inc. America’s state of mind. www.
9. IMS Institute for Healthcare Informatics. The use of medicines in
the United States: review of 2011. www.imshealth.com.
10. Mark TL, Levit KR, Buck JA. Datapoints: psychotropic drug prescriptions by medical specialty. Psychiatr Serv 2009;60:1167.
11. Wang PS, Aguilar-Gaxiola S, Alonso J et al. Use of mental health
services for anxiety, mood, and substance disorders in 17 countries in the WHO World Mental Health Surveys. Lancet 2007;
12. Fuller Torrey E. Out of the shadows: confronting America’s mental illness crisis. New York: Wiley, 1997.
13. Leucht S, Hierl S, Kissling W et al. Putting the efﬁcacy of psychiatric and general medicine medication into perspective: review of
meta-analyses. Br J Psychiatry 2012;200:97-106.
Public release date: 12-Jun-2013
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Contact: Tomi Gomory
Florida State University
[ Print | E-mail | Share ] [ Close Window ]
Contact: Tomi Gomory
Florida State University
Down the wrong path: Book details psychiatry's lack of objective science
TALLAHASSEE, Fla. — Psychiatry — which uses well-intentioned coercion, unscientific diagnoses and psychoactive drugs that do as much harm as good — is a science that is off course, according to a new book co-written by Tomi Gomory, an associate professor in the Florida State University College of Social Work.
In "Mad Science: Psychiatric Coercion, Diagnosis and Drugs" (2013, Transaction Publishers), Gomory and co-authors Stuart A. Kirk of the University of California-Los Angeles and David Cohen of Florida International University discuss several keys points that the international psychiatric community is beginning to wrestle with, including the description of troubling human behaviors as medical diseases.
"No one doubts that people have strange behaviors, but how you explain those behaviors is important because strange behaviors are not necessarily medical diseases or the result of them," Gomory said. "This is where psychiatry has gone down the wrong path."
"Mad Science" is the most comprehensive of five recently published, scholarly books that take a critical look at the notion of medical psychiatry and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), the bible of psychiatry. Even the National Institute of Mental Health criticizes the DSM for its lack of objective laboratory measures, Gomory said.
Gomory and his co-authors base their claims on eight years of reviewing mainstream research and analyzing the history of madness and psychiatry as well as the language of psychiatry. In the final chapter, they envision a "nonmedicalized" future of helping the seriously emotionally troubled members of society.
The scientific character of medical diseases includes physiological lesions or signs as well as more subjective symptoms or patient complaints. Psychiatric "diseases" have no lesions or physical markers.
"There isn't any science behind labels such as schizophrenia, bipolar disorder, post-traumatic stress disorder or any of the more than 300 mental illnesses that the DSM psychiatric work groups have created," Gomory said. "They are merely arbitrary conceptual categories with no legitimate medical science to back them up."
Gomory points to brain lesions, which are the identifiable biological markers of an overwhelming number of neurological diseases. Yet there are no such markers for any of the behaviors that psychiatry describes as a disease or mental disorder.
"We argue that simply labeling troubling human behavior as a brain disease is not the answer," Gomory said. "Neurology is the medical profession that handles brain diseases, so anything that is a legitimate brain disease should be identified and treated through neurology, not psychiatry."
When it comes to using psychotropic drugs to treat troubling human behaviors as if they were medical diseases, psychiatry has proceeded on uncritically accepted claims, rather than well-tested evidence.
"Psychiatric drugs are not a panacea by any means," Gomory said. "Many of these drugs are black-labeled by the Federal Drug Administration, which is its most serious warning. In many cases, the things you think they should decrease they increase for many people."
Antidepressants, the latest of which are known as selective serotonin reuptake inhibitors or SSRIs, are habit forming, can increase anxiety or make people suicidal. Antipsychotics, which suppress central nervous system activity, are used to manage very disturbing behavior. They can lead to serious weight gain, diabetes and heart disease and can cause various neurological disorders including tardive dyskinesia, a permanent, physically disfiguring movement disorder.
"These are more than casual side-effects, but serious, adverse conditions in themselves," he said.
When it comes to solving behavior that is strange, absurd or frightening, Gomory says that society should work within psychological, social, ethical and moral parameters rather than medical parameters, and never rely on coercive measures such as forced institutionalization.
"There is no science to back up the validity of psychiatric coercion, essentially locking people up or forcing them to take medication, because the literature is clear we can neither predict or prevent serious self-harming behaviors," Gomory said.
People with strange behavior who don't want help and are not harming others or themselves should be left alone, according to Gomory.
"If someone is hearing voices and they find that is a problem, then you help them," Gomory said. "Others might consider the voice to be a benign companion, like the imaginary friends of young children. We should not make helping a coercive activity, but we should offer to help anyone who wants help using the strong evidence base available for psychosocial treatment approaches for troubled or troubling behaviors."