The Emperor's New Diagnosis

1. The Emperor's New Diagnosis Human Suffering and the DSM

2. Do I Have a Disorder?

3. When Do We Use Diagnoses? • Reimbursement. • Communicating with colleagues. • Communicating with clients.

4. 1. Reimbursement Insurance companies and government agencies want to ensure that people only receive a treatment if they need it and that they are being given the most appropriate treatment for their problems.

5. 2. Communicating with Colleagues We are trying to convey the most pertinent information about the client and give our colleagues the highest quality understanding of the client's situation.

6. 3. Communicating with Clients We are trying to help the client understand what they are experiencing and why.

7. Is the Medical Model the Best Way to Accomplish These Aims? • We will explore the ideas of "mental illness" or "mental disorder" and psychiatric diagnosis with the aim of answering two questions • Are "mental illnesses" real? • Is thinking in terms of "mental illness" and diagnosis the most helpful to our clients?

8. Defining the Medical Model • There is such thing as “true mental illness” or “chemical imbalance” in which psychological symptoms cannot be understood in terms of the person’s psychology. • "Mental illness" can be divided up into a finite number of discrete diseases, such as schizophrenia, bipolar disorder and major depression.

9. Emil Kraepelin

10. Robert Spitzer

11. Where Did the Medical Model Come From? Emil Kraepelin's optimism. • The German psychiatrist and contemporary to Freud proposed the existence of psychological diseases. • It was just after Louis Pasteur proposed the Germ Theory of Disease. • The shift from imbalances and humours to looking for germs and diseases led to cures and vaccines.

12. Medical Breakthroughs of the Early 20th Century

13. What Did Kraepelin Believe About Mental Diseases? • Any real disease must share common symptoms, etiology and treatment. • Since so little was known about etiology and treatment, Kraepelin sought to group symptoms. • He believed that if he could group them correctly, they would also share an etiology and treatment.

14. An Example of a Real Psychiatric Disease • Wilson’s Disease is caused by mutations in the Wilson’s Disease Protein Gene (ATP7B) which causes copper accumulation. • Wilson’s Disease causes depression, anxiety and psychosis in addition to tremors and jaundice due to liver and nervous system damage. • Removing copper from the system (through chelation) prevents further damage.

15. 100 Years After Kraepelin • After grouping and regrouping symptoms for 100 years, discovery of psychological diseases with symptoms, etiology and treatment response that properly cohere has been extremely rare. • Over 90% of mental health complaints are not caused by a known psychiatric disease.

16. What Would Kraepelin Think? • His ideas unequivocally did not lead to the type of advances he had hoped. After 100 years, I think he would tell us to stop looking and find another paradigm.

17. Why is the Medical Model Popular? • If "mental diseases" were real, we might be able to discover a cure (like antibiotics) or even a vaccine (like polio). • Some people believe that if psychology were more like medicine, it would make it a more legitimate profession. • The pharmaceutical industry makes over a trillion dollars each year with drugs that aren't very effective. They want people thinking in terms of medicine for "illnesses."

18. What Did Spitzer Do? • Robert Spitzer was the creator of the DSM-III and chiefly responsible for taking Kraepelin’s ideas from relative obscurity to being the dominant paradigm in the mental health field. • The adoption of DSM-III in 1980 was the most decisive move in the history of mental health away from thinking in terms of personal experience and the uniqueness of the individual in his social context, and toward the medical model.

19. How Big Was Spitzer’s Influence on the Field? • DSM-I and DSM-II both represented the view of psychological problems as being expressions of inner-conflict and difficult life experiences that were only able to be properly understood by understanding the individual or family. • Spitzer’s DSM-III was the decisive break to a view of psychological problems as being best understood as specific disorders. There is no longer a need to understand the context.

20. The Crisis in the 1970’s and the Need for a New Paradigm • A broad antipsychiatry sentiment from Thomas Szasz and Michel Foucault to One Flew Over the Cuckoo's Nest. • Third-party payers demanding that psychiatry demonstrate the efficacy of their practices as they wanted to be paid to treat people with increasingly mild distress. • Pressure from the emerging field of psycho-pharmaceuticals to be able to market their drugs for specific diseases and newly deinstitutionalized patients. • Conflicts between various theoretical camps, and those who viewed psychological theories as too subjective. • Psychiatrists feeling threatened by other professionals delivering psychotherapy (Resnick vs. Blue Shields, 1980).

21. Who Did We Choose As Our Savior? Robert Spitzer and Charts Spitzer quote: "When I was 10, 11 or 12 I went to summer camp and my bed was against the wall and on the wall I made a graph of my feelings towards 5 or 6 ladies and over time went up and down. That's a strange thing for somebody to do but that's the kind of person that I guess that ends up doing what I did, in other words translating feelings into some kind of a system." NPR interview, 2003.

22. The Creation of DSM-III • In 1974, diagnosis was an unpopular specialty. Spitzer was able to appoint himself to head all 25 committees. • Findings were not based on any research, but on the consensus that emerged from small rooms of psychiatrists arguing with each other. • Columbia Professor David Shaffer explains…

23. The Height of Subjectivity • In those small room discussions, they concluded that racism was not a disorder, but that PMS was. Spitzer favored viewing homosexuality as a disorder, but bowed to pressure from activists. • Spitzer says that the DSM-III (created with no research) made psychiatry “feel” more scientific when it was adopted in 1980 in the same 2003 NPR interview.

24. Robert Spitzer and Human Emotion • Spitzer does not view himself as understanding very much about human emotion. Instead he views his talent as being able fitting puzzle pieces into a system, as he relates in the 2003 NPR interview.

25. After the DSM • After being denied the position of directing the DSM-IV, Spitzer did not continue to pursue an interest in human emotion. He pursued his interest in categorizing things. • He created an elaborate system for categorizing ballroom dancing, as explained in the 2003 NPR interview. • The ballroom dancing community has been less willing to adopt Spitzer’s ideas than psychiatry has.

26. Why Did the Rest of the Field Follow Psychiatry • Private insurance companies had usually required a diagnosis. They became stricter. • There was a growing shift from out-of-pocket payment for therapy to increasing reliance on third-party payers. • Government funders increasingly required diagnosis. • This was all largely due to the most influential mental health professionals in government and private insurance being psychiatrists.

27. Does Diagnosis Increase Therapeutic Efficacy?? • While a fair amount of research has been put into trying to prove the DSM’s diagnoses are reliable, there has not been a single study aimed at testing whether using diagnoses increases therapeutic outcome. • All evidence shows that mental health treatment as a whole has not improved since diagnosis has become ubiquitous.

28. If Not Disease, Then What? • Symptom-oriented descriptions • List of symptoms and severity. • Complaint-oriented descriptions • Describe patient/client’s own reason for seeking treatment. • Terms like "serious mental instability" or “multiple psychotic breaks” rather than "serious mental illness” or “schizophrenia”.

29. Does It Matter If We Believe in Mental Illness? • Communicating with clients: Diagnosis vs. their unique experience and symptoms to help them understand themselves. • Communicating with colleagues: Diagnosis vs. one sentence describing symptoms and one or two describing history to convey clinical relevance. • Third-party payers: Diagnosis vs. list of symptoms and severity to unsure appropriateness and necessity of treatment.