The Art of Diagnosis

Friday, December 26, 2008


Does very severe PMS constitute a mental disorder? That's one of many questions facing psychiatrists as they work to revise the Diagnostic and Statistical Manual of Mental Disorders or DSM, the definitive compendium of our psychic maladies. Because the DSM influences not just doctors and patients but medical research, insurance companies, the pharmaceutical industry, advertising and the culture at large, controversy surrounding its new edition abounds. Brooke looks at this powerful book.

Comments [18]

Donna C from Austin, Texas

I'm an LCSW and use the DSM daily. I remember when in school, I thought *I* had everything in the book. I finally understood the DSM is a guideline for diagnostics, not a list of definitive diagnoses. Mental illness IS real. I function normally and am a gifted clinician, yet when I developed GAD due to a heart condition, I was unable to function at all. I feel blessed there was a psychiatrist who was able to help me work through my break by combining medications and talk therapy. As a professional, I use the DSM as one of many resources in my diagnosing of clients. I would hope other professionals also recognize that this book is just a resource like any other. Yes, the DSM is based on a discussion among professionals and as such is rife with opinion, but how else do you think progress occurs?
Yes, SOME psychiatrists are simply "pill pushers for the drug companies"; however do not indict everyone for the behavior of a few. Remember, medical doctors used to "blood-let" to get rid of an illness.
No, there isn’t a lab test to identify the chemical imbalance that causes mental illness. Perhaps someday there will be. There weren't lab tests for many of the other chemical imbalances that fall under the umbrella of physical health until they were developed. It seems so simple to me. Our bodies run on a system of chemical balances and electrical impulses. If the malfunction of the chemical balance can cause physical illness such as diabetes, why is it unreasonable to assume other imbalances could cause mental illnesses?
I hope professionals recognize the DSM as only one of many resources to utilize when treating a client.
I hope society begins to comprehend that for some people, life is painful and impossible without medication and it is cruel to discount their pain as "not real" because there is no scientific test to prove the symptoms. I would hope society realizes the definition of a continuum and realizes we all fall along that line somewhere.

Jan. 12 2009 03:06 PM
Irene G from Boulder, Co

In my counseling of people, I have found it extremely hard to work with people after they have been to a psychiatrist and put on multiple drugs. Looking into this, I have learned that there are several flaws in the logic supporting the DSM and this report. 1) The DSM is based on science. This if false. It is based on opinion, conjecture and business. 2) The DSM existents to help diagnose mental illnesses and disorders. The DSM exists to broaden the categories of “mental illnesses” to expand the market for pharmaceuticals. 3) Psychiatrists are concerned with helping people. Their barbaric history of drugging, torture and abuse of patients, psychiatry is been a black spot on the medical profession for over 150 years.

Jan. 02 2009 09:25 AM
Steve B from Boston, MA

The DSM is a closed door process because it hides the fact that it lacking real, hard science to determine its content. If the medical profession, insurance companies and government understood the process of DSM deliberations, they would not support the use of the DSM any more than the use of astrology, alchemy or reading the entrails of butchered goat.

In my profession, engineering, you work with solid principles that produce a product that functions as intended. You can drive a truck over a bridge and it stays out of the river. If this were the case of the DSM, it would be getting smaller rather than fatter. Step back and look at the products of psychiatry: addicting drugs, expensive hospital stays and poor results are all they have to show for their efforts. The truck is in the river.

Jan. 02 2009 09:19 AM
Chris Gray from New Haven

Sorry, Nazanin, your apology just doesn't wash with me.

I noticed, as I was listening to the program, that this show seemed to have much more music than usual and I felt that it was padded with it. You could easily cut back on it and given us more of the interviews.

As to Michael Roth's comment, there is wisdom in it and not a whole lot in popularity contests by competing opinion pools.

Jan. 01 2009 02:55 PM
Michael Roth from Staten Island, NY

Near the end of this story on the DSM, Brooke opined that the process of creating the next edition of the DSM should be open to greater public scrutiny. The topic of Social Anxiety was brought up as an example of over diagnosis.
Anxiety (or Generalized Anxiety Disorder) is a diagnosis, but not everyone who has ever felt anxious should receive that diagnosis. If you just get nervous addressing a crowd then you are likely normal. If you are too anxious to ever leave your home then you may have a mental illness. The DSM says when and where to draw that line. The last thing we need a public tug of war between people who deny the existence of all but the most severe mental illnesses and drug companies who just want to sell a product. Let the experts deliberate. This isn't a popularity contest.
Hopefully the next DSM will move the field towards greater consensus. If it doesn’t then doctors will continue to stray from the guidelines and experiment, much as they do now.

Dec. 30 2008 04:26 PM
Neal Fox from Florida

Yeah. People have problems. But problems are not diseases.

The mental health profession is about as scientific as palm reading.

Out of the millions of people who have been told they have a chemical imbalance in the brain, not one of them can show you their lab reports. Why? Because there are no lab tests for this. The only thing know for sure is the drugs CAUSE a chemical imbalance.
Let's make the psychiatrists prove their theories before we give them any more tax dollars.

Dec. 29 2008 06:15 PM
Nazanin Rafsanjani from New York, NY

Dear Stef and Brenda,

Thank you both for listening and for commenting on the site. As the producer of this piece I wanted to try to explain our choice of the song “Don’t Worry Be Happy” for the end. We were not trying to make light of anyone’s suffering, nor were we trying to imply that there is no such thing as mental illness. Throughout the piece we moved from very briefly discussing Gender Identity Disorder to PMDD to Social Anxiety Disorder to the DSM generally but we also talked about overdiagnosis of mental illness. We ended the piece on the issue of overdiagnosis with that last q&a between Brooke and Dr. Regier. The song was meant to address the issue of overdiagnosis, not diagnosis in general. With that said, I can see why it bothered you both and I apologize for that.

Also, to Stef, I just wanted to say that I really wished we could have used more of your interview. I thought it was an honest interview and we wanted to try to fit more of it in but we just ran out of time. We had the same problem with every guest. We talked with some of them for over an hour and were able to use just a minute or two. That was a real challenge for this piece. There was so much to cover and so little time to do it in. I did really appreciate your taking the time to talk with us.

Thank you all for leaving your comments.


Dec. 29 2008 11:01 AM
Stef from San Antonio, TX

This is Stef with and I spoke with them for about 30 minutes, though only about 3 sentences were said.

I was bothered by the don't worry, be happy at the end as well. It is so difficult for a lot of us to come out and be so bold in order to help others and then that, it almost made it joke like.

Also, I know that a lot of my interview wasn't played I guess because it was so much about PMDD, since that's what I blog about and live with and this was more about the DSM.

My interview was serious and I went into more detail on the things I spoke about that were mentioned quickly.

Living with PMDD is serious and does interfere with a Woman's life and her families life. To push it to the side and make light of it, just shouldn't happen.

As far as it being something we could all just learn to live with, I receive tons of emails and comments on my blog from husbands and boyfriends wanting to know how they can help because it is so much more extreme than just PMS.

I just wanted to add my 2 cents since a lot of it wasn't added.

Dec. 28 2008 11:33 PM
Brenda Phillips from Grand Rapids, Michigan

My conscience is bothering me. I shouldn't have used the word "stupid." I apologize.

Dec. 28 2008 10:22 PM
Jonathan R. from San Francisco

So what if 80% of New Yorkers are neurotic, or 50% of people shy? "Normality" is neither a bright line nor an ideal, but a mere statistic. We don't have this argument in the realm of physical health. It used to be "normal" to live to age 50, for mother and/or baby to often die in childbirth, for millions to suffer and die from a thousand venereal and water-borne diseases. That normal changed after improvements in drugs, nutrition, hygiene, plumbing and sewage systems, etc.

Numerous studies confirm the obvious fact that shy people are both less happy and less successful than sociable people. If they seek help, we should help them. Neither reluctance to change the "normal" nor objection to someone's profit is a serious argument against improvement in health, either mental or physical.

Dec. 28 2008 08:17 PM
Brenda Phillips from Grand Rapids, Michigan

As an individual who has struggled with bipolar disorder, schizophrenia and borderline personality disorder for a lifetime and who has been disabled and on medication for over a decade, I found stupid, naive, irresponsible and offensive Brooke's conclusion that the DSM overdiagnoses psychiatric conditions; the playing of the song "Don't Worry, Be Happy" implied that we can all just will ourselves to be happy and free from worry, that mental illness is nothing to be concerned about, and misses the entire point of the DSM - the DSM is designed to diagnose those of us can't just will ourselves to have whatever good emotion we wish, those of us who are tormented by mood disorders, hallucinations, cognitive problems, and emotional confusion and pain. Thanks for nothing, Brooke - your report did absolutely nothing for the DSM and nothing for the mentally ill, who could use your help, especially because so many mentally ill are needlessly incarcerated because the mental institutions have been closed. You should be ashamed of yourself; for a program that is supposed to be a watchdog of the media, you have miserably failed those of us who most need your objectivity.

Dec. 28 2008 08:17 PM
Vicki Siedow from Los Angeles, California

Bravo! an excellent, insightful piece of responsible journalistic reporting. I, too would love to hear follow up pieces on this topic. How about the many quiet payoffs that have been coming to light, from pharmaceutical companies to those in a position of influence, who then forward the pharma line of propaganda? I have seen a lot of research and articles on that topic lately. The public needs to know the true motivation behind these manufactured maladies, diagnoses and subsequent drug sales.

The psychiatric machine has gradually turned any sort of emotion, feeling, or individuality into an aberration to be drugged into numbness, for their profit. We're becoming a laboratory nation of zombies, with no personality or responsibility. I'm grateful that NPR is willing to buck the tide and put things in perspective. So many lives are ruined or lost because of big pharma greed.

Dec. 28 2008 06:03 PM
Chris Gray from New Haven

Back in the '70s, while in New Haven's Exit Theater, we performed William Packard's poem "My Name Is Bobby" as a play. It was created from the words of a boy who had undergone a prefrontal lobotomy and the words that kept jumping out at me were, "The hate rays! The hate rays!" and, for several years after coming home to find a roommate dead, I spent a lot of time awake only at night, when I felt there were far less of them.

That was pretty severe social anxiety, so I have no doubt that it is a true disorder, though I have also no doubt that big pharma and quacks have jumped on it as the goldmine it has turned out to be.

I suppose it is a good thing 'House" deals primarily with physical maladies, elsewise we'd become familiar with far more possible mental ones, since he usually misdiagnoses about five times in each episode.

Keep up the medical reporting exposes. We need them.

Dec. 28 2008 05:21 PM
Jim Clark from Austin,TX

Well Done - a great program. You are taking on the tiger right in the teeth! Bravo!!!

Keep up the effort - greater stories to come.I look forward to hearing more. There's enough in what you've started here to create an entire program series on the psychotrophic medico BIg Pharma complex. The (social) disordered definitely NOT listed in the Diagnostic and Statistical Manual of Mental Disorders or DSM. But instead would be its epitaph - a fitting epiteth*(disparagment)!

Dec. 28 2008 11:20 AM
Dan Eley from Muskegon, Michigan

Speaking of living in a glass house: I misspelled my city. It is corrected above. I "regret the error".

Dec. 27 2008 10:55 AM
Dan Eley from Muskergon, Michigan

"Dose very severe PMS constitute a mental disorder?"

"Dose" this constitute a typo?

Dec. 27 2008 10:49 AM
Richard Johnston from Upper west side

Notwithstanding the high quality of the reporting, there are constant grammatical errors, in this case "all but one was diagnosed as schizophrenia."

Dec. 27 2008 07:55 AM
Gail from Naperville, IL

I wish that social anxiety disorder would stop being the "go-to" fake diagnosis in stories like these. It does exist, and it can ruin your life.

I have social anxiety disorder. I grew up as a shy kid - but I had friends, I did well in school, could speak in public, and had romantic relationships. But, as I got older, my anxiety in public situations got worse. But, I'd hear over and over again how "everyone" is shy. "Everyone" has problems talking to new people. I honestly thought that I must be a very weak willed person to not be able to get over feeling like I was going to die if I had to walk up to that unknown person at a party. I thought "everyone" hyperventilated at the idea of talking to a professor. I thought "everyone" was completely unable to answer their phone at home. Honestly, I thought everyone felt that way, and everyone but me just got over it. By the time I was diagnosed, I could barely drag myself to work, I could not talk to strangers at all, and I had no friends. I had one long suffering boyfriend who had to deal with my locking myself in the bathroom and crying when he tried to have me talk to his aunt on the phone.

Then, I saw that first commercial for paxil. It was like a light bulb going off. It was the first time that I realized that it wasn't normal to feel the way I felt. Now, I sat on it for awhile - after all, to get diagnosed, I'd have to call the dr. And I didn't think I could do that.

Today, 8+ years later, I'm a lot better. I take medication every day (not paxil) and I have therapy once a week. I have a fiancé, friends, I go to parties, host friends at my house, and I have an awesome job. I am very lucky.

Dec. 26 2008 06:53 PM

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