K: The ever-expanding definition of mental illness; increasing rates of psychological disorders; criticisms of the latest DSM; Vague definitions of mental illness; loose guidelines for psychological disorders; New psychological disorders; overdiagnosing children
“When you visit a mental-health practitioner in the U.S., exercise extreme caution. Realize that the official guidelines now in force are not guidelines at all, but rather a license to diagnose anybody with anything.”
– Dr. Leonard Sax, physician and psychologist
One of the most frequent criticisms leveled at the American Psychiatric Association and it’s diagnostic manual is that it’s grown so vague and all-encompassing that it can be used to diagnose anyone with just about anything. What started out in 1952 as a spiral bound pamphlet has grown into a 947 page monstrosity with the latest publication of the DSM-5. Volume isn’t necessarily a bad thing. As an author, I know all too well how page count can quickly climb as you try to present research and case studies to firmly establish your position. but rather than becoming more precise, it’s only become more vague, and the increase in size has been mostly due to a vast expansion in the number of official mental illnesses. Several things have happened to loosen the diagnostic criteria:
The addition of new disorders The DSM has been steadily adding new disorders to its list of ailments, many of which have little to no scientific basis behind them. Among the more controversial ones are things like …
- Caffeine intoxication (Drink too much coffee? You’re mentally ill.)
- Parent-child relational problem (Is parenting hard at times? This might be a disorder!)
- Antidepressant discontinuation syndrome (So after they put patent on meds that don’t work for a condition they never had, they can now bill insurance companies for helping these patients get back off their medication.)
- Unspecified mental disorder (if you don’t have any other disorders, you can qualify for this disorder)
Many of these new conditions turn normal adversity into mental illness. The latest DSM, for example, eliminated the “bereavement exemption” from the diagnostic criteria. Even before, you only had two weeks to get your head back on straight after a loved one died before your grief symptoms officially became a mental illness. Now there is no grace period. So under the new DSM-5 guidelines, normal grief will become a mental illness. (Bower, 2013) In his book Saving Normal, Dr. Allen Frances reacts to these changes with alarm, complaining that the DSM-5 is riddled with “new diagnoses that would turn everyday anxiety, eccentricity, forgetting, and bad eating habits into mental disorders.” Under the new guidelines, he says, his 6-year-old twin grandsons wouldn’t have tantrums but would rather suffer from “disruptive mood dysregulation disorder.” As for his own tendency to forget names and faces on occasion, this would earn him the stamp of “mild neurocognitive disorder.” (Tavris, 2013)
One diagnosis that (thankfully) never made the cut was “atypical child”; not because there wasn’t plenty of people rallying in support of such a diagnosis, but because Robert Spitzer’s committee could never agree on how to define it. Roy Richard Grinker jibes that the diagnosis “might just as well have been called FLK (funny-looking kid), because it was one of those catchalls – like the suffix ‘NOS’ (not otherwise specified).” (Grinker, 2007, p. 117)
While the “funny looking kid” diagnosis never did make it into the DSM, plenty of other dubious conditions have. The most recent update (the DSM-5) saw the addition of the new condition “Unspecified Mental Disorder” on p. 708. The one and only requirement for diagnosis is that you “do not meet the full criteria for any mental disorder.” In other words, you (or your child) can be labeled crazy precisely because you do not fit any of the other requirements for being crazy. Now that’s crazy.
A more subtle yet equally powerful expansion has come from the loosening of diagnostic’ criteria. Each disorder has a checklist of symptoms: Does this patient hear voices, do they experience delusions of grandeur, etc. If they exhibit any 5 of these 8 listed behavioral symptoms, or perhaps 3 out of 5, they qualify for the disorder. This is how the checklist works.
Over the years this checklist has grown ever more forgiving. Maybe instead of 5 symptoms, they only need 4. Or instead of symptoms from two separate categories, they only need symptoms from one. The definition of these symptoms has also grown more vague over the years. The end result is that it’s become steadily easier to diagnose children for various conditions.
NOS: The APA’s acronym for “BS”
What to do with the infamous NOS category. For those of you not initiated, NOS stands for Not Otherwise Specified, and it has become the crutch of the psychiatric industry. Many conditions allow for an NOS category, which means that if a patient doesn’t fit the technical criteria for a particular condition, they can still be diagnosed with it anyway under the not otherwise specified label. There is a category for mood disorder-NOS, autism disorder-NOS, anxiety disorder-NOS, and most recently, ADHD-NOS, among others.
The NOS category is insulting enough to science simply on its own. But the real problem is that for many disorders, the NOS category is the one most often used in practice. Which means that a good portion of the people being diagnosed with mental health disorders don’t actually fit the criteria originally intended for that disorder.
As if ADHD wasn’t over diagnosed enough already, the DSM-5 added a catchall not otherwise specified label to this condition too, so that children who don’t meet the official guidelines for ADHD can nonetheless be diagnosed with ADHD. The only requirement is that the subject has problems paying attention from time to time in a way that causes “significant distress or impairment.” (Again, no guideline’s on who’s actually distressed – the parent or the child, nor what should qualify as “significant.”)
When diagnosis leads to medication
These vague and all-encompassing definitions of psychological and behavioral disorders wouldn’t be so bad if it simply meant therapists helping patients with problems. (Though there are dangers here, too, since therapy can hurt as well as heal.) But far too often these diagnoses result in patients – and particularly children – being put on powerful psychological drugs. It ends up acting as a license to drug up any child with stimulants or antipsychotics for disorders they don’t actually have.
The issue of multiple diagnoses
Many behaviors that are considered problematic are listed as symptoms for multiple disorders. When you combine this with the “fuzzy boundaries” defining many mental illnesses and separating one from the other, it means that “as with previous manuals, most people deemed to have one DSM-S disorder will also have one or more additional disorders.” (Bower, 2013, p.6) Thus many kids are going to leave the doctor’s office having been strapped with more than one diagnosis. (Jabr, 2012)
This is a rather insidious practice. Most people aren’t going to recognize that these multiple diagnoses simply represent a duplication of the same symptoms across different diagnostic labels, all of which are artificial groupings to begin with. They’re going to interpret it to mean that they (or their child) has two or three problems as opposed to only one. This simply isn’t the case. Your child merely exhibits symptoms that could fit into multiple categories, and your doctor or therapist has chosen to checkmark these categories to describe your child’s symptoms. IT DOES NOT MEAN THEY ARE TWO, THREE, OR FOUR TIMES MORE DISTURBED THAN THE AVERAGE CHILD.
The symptoms or behavior a child exhibits is the only thing that’s real. The diagnostic labels are not real. They are simply a way to group and recognize clusters of symptoms for reference and insurance purposes. Remember this is your child is given multiple diagnoses. Focus on the child you’ve always had, and treat the labels as superfluous, because that’s precisely what they are.