Is it a Symptom or a Syndrome? Psychology’s Struggle for Legitimacy

Creating an effective and accountable standard of measurements to determine the efficacy of psychotherapy is a perplexing task made even more confusing by the DSM itself.  The Diagnostic Statistical Manual of Mental Disorders is the sourcebook of diagnostic criteria for mental health professionals and the basis of all insurance reimbursement.  The biggest problem with the DSM is that you can’t define a mental disorder using the manual.  The DSM is simply a cluster of symptoms that clinicians use to come to some general consensus of a diagnosis.  It does not allow for personal perception and often does not take into account contributing circumstances, such as culture and ethnicity, which can sharply influence how symptoms are experienced and reported.  It also doesn’t take into consideration the review of process notes, nor does it suggest forms of treatment for specific disorders.  Additionally, even if you could define mental illness the pharmaceutical companies have such a large stake in developing medications for mental disorders that they routinely elevate everyday suffering to the level of a mental disorder.  It’s been widely documented that more than 50% of the experts on panels overseeing current and future DSM updates have financial ties to drug companies.  With such obvious limitations and conflicts of interest baked into the system it’s no wonder there’s such a strong backlash against overused diagnoses such as ADHD, Generalized Anxiety Disorder and Bipolar Disorder.

The controversy between socially constructed diseases and verifiable illnesses has been going on since the DSM was first published in 1952.  In the early 1970’s homosexuality was just being delisted in the DSM II.  In 1980 “neurosis” was removed from the DSM III.  In 1993 feminists argued against the inclusion of Premenstrual Syndrome, which was being considered under the name Late Luteal Phase Dysphoric Disorder”.  Once accepted, a label creates its own self-reinforcing loop of treatment, reimbursement and medication.  Over time, it becomes part of our vernacular.  Although the term “neurosis” has not been active in the DSM for thirty years we still know many people who are neurotic.  According to the National Institute of Mental Health (NIMH), at any given time 26% of all adults suffer from mental illness yet in only 5% of the cases is the disease serious enough to cause any disruption to daily life.  The unsavory conclusion to the proliferation of mental illness in our society is that it has become a big business.  Too big, in fact, to be contained.  Without the ability to clearly differentiate everyday suffering from a mental disorder we run the risk of over diagnosing, over medicating, and perpetuating the extraordinary rise of mental illness in America.

Critics argue that creating more diagnostic categories can help catch a disease in its early stages and keep it from becoming more severe later in life.  Psychological tests are also becoming increasingly sophisticated and can define illness more accurately than ever before.  The counter argument is evident in the 4,000% increase in the diagnosis of childhood bipolar disorder since its inclusion in the DSM.  The problem with this diagnosis is that most of the children diagnosed never had the syndrome to begin with; they were simply misdiagnosed.  To rectify this situation a new disorder category is planned for the DSM V called Temper Dysregulation Disorder with Dysphoria (TDD), also known as “having a bad temper.”  Not to be overshadowed by Childhood Bipolar Disorder, there is a raging debate in the inner circles of the DSM review panels about whether or not to include “Psychosis Risk Syndrome,” a disease characterized by pre psychotic behavior in adolescents, in the upcoming DSM V.  Opponents fear it will create another disorder that will be over diagnosed and under developed resulting in a fate similar to Childhood Bipolar Disorder.  While proponents say that if caught early enough there is a possibility of staving off the effects of psychosis in later life, unless, of course, there’s no correlation between the two in the first place.

The controversy between diagnosis, treatment and reimbursement is causing the field of psychology to move towards a more scientifically based approach to research and outcome measures.  Often considered the step-child of science, psychology is fighting to maintain its dignity.  The proof, however, will not be found in traditional methods of doing psychotherapy, or in the DSM, which is far too subjective to be scientific.  It will most likely come from the advancement of neuroscience, which is finally giving psychology its scientific foothold by pairing brain scans with behavioral maladies much like medicine uses blood tests and other more objective criteria to diagnose illness.  By as early as 2020 psychology may finally achieve some legitimacy in the scientific community.  Interestingly, Freud was a neurologist before he became interested in psychopathology.  Early in his career he tried to find the link between brain processes and human behavior.  Now, one hundred years later, psychology is trying to complete the circle.  The scientist in Freud is encountering the “talking cure” he created to bring together the body and mind in one movement called, “Neuropsychoanalysis”, which enthusiasts hope will bring psychology to the Promised Land.  Through brain technology, psychology will be able to validate itself as a science and render the subjective field of human interaction to a subcategory of this new model.  Instead of completely blowing up the old model, the “talking cure” will remain alive and well as a subsection of “Neurosomething” where it will live in subjective peace and quiet, untouched by measuring devices but still able to touch the clients who seek it out.

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