What’s A Mental Disorder?

What’s A Mental Disorder? Even Experts Can’t Agree
December 29, 2010

“Pediatricians and child psychiatrists would see kids who could talk but who had social discomfort — severe social discomfort — and awkwardness and a very restricted and impairing level of interests and activities, and they wanted a diagnosis for this,” Frances says.

A study was done to figure out how common Asperger’s was, and the results were clear: It was vanishingly rare. Then Frances put it in the DSM, and the number of kids diagnosed with the disorder exploded. Frances remembers sitting in his condo reading articles about this new epidemic of Asperger’s that was sweeping the nation.

“At that point I did an ‘oops,’ ” he says. “This is a complete misunderstanding.


Why is DSM-5 so much like DSM-IV?

Why Is Psychiatry’s New Manual So Much Like The Old One?
by Jon Hamilton
May 16, 2013

Specifically, DSM-5 will continue to use symptoms as the primary way to decide whether a person has a particular disorder. That may not sound odd until you consider what’s happened in other fields of medicine, like cardiology.

The Hippo Problem

But now, many scientists are concerned that this emphasis on the signs and symptoms of a disease “could be seen as holding us back,” Desmond-Hellman says. Instead, she’s been advocating something called “precision medicine,” which tries to classify diseases in a way that indicates what’s truly causing the problem.

The human brain is the most complicated thing in the universe. It has nearly 100 billion neurons and many trillions of connections, and its complex wiring changes all the time.

DSM disorders overlap … with normality

DSM-5 “Addiction” Swallows Substance Abuse
Psychiatric Times. March 30, 2010
Allen Frances, MD

All the DSM disorders overlap with one another and frequently also with normality.
For example, there is no clear boundary between bipolar and unipolar mood disorder, between anxiety and depression, even between schizophrenic and psychotic mood disorders, and so on throughout all the sections.

Less and less willing to sit with our emotions

How Medicalizing Grief Turns Into Dollars
Forbes. February 21, 2012

grief, once excluded from the definition of depression, is now included within it.
This means that people grieving over the death of a loved one could theoretically go to their psychiatrist and be prescribed pills to treat the “condition.”

The Lancet beautifully outlines why the medicalization of grief is misguided for so many reasons.
Antidepressants don’t do anything to the moods of non-depressed people, they point out, so there’s little likelihood that they would work to reduce grief.
Arthur Kleinman, a medical anthropologist, says that since the APA wants to allow for treatment of the normal grieving process, it had to first yank it from Normalcy and plunk it down in the realm of Abnormal, or worse, “make it over into a disease—ie, depression.”

the DSM continues to shorten the normal grieving processes.
The DSM-III considered grief for up to one year acceptable, the DSM-IV only two months.
No other culture, Kleinman says, considers two months a normal amount of time to grieve. They must be shaking their heads at us silly Americans and our strange attitude towards grief. Cultures across the globe vary hugely in what’s considered a normal timeframe to grieve, some devoting the remainder of the lifespan to mourning the loss of a loved one.

a fundamental difference between grief and clinical depression: grief, in many ways, makes sense, as there is direct cause for the feelings of sadness, loss, sleeplessness, and lack of concentration.

Would you want to take a medication if it would help lighten the pain of grief?
Or is it better to experience it, work through it, and wait for it to lift in its own time?
There is undoubtedly a place where grief becomes depression when it does not lighten for a long time.
But considering it a symptom of depression from day one seems like a damaging way to define it.

see also:


CRAZYWISE: A Traditional Approach to Mental Illness
Phil Borges
Jan 2, 2016

When a young person experiences a frightening break from reality, Western experts usually label it a “first-episode psychosis”, while many psychologists and cultures define it as a “spiritual awakening.

Mental health: On the spectrum

Mental health: On the spectrum
Nature 496, 416–418 (25 April 2013)
David Adam
Research suggests that mental illnesses lie along a spectrum — but the field’s latest diagnostic manual still splits them apart.

diagnosed with several disorders, or co-morbidities: About one-fifth of people who fulfil criteria for one DSM-IV disorder meet the criteria for at least two more.
These are patients “who have not read the textbook”

Psychiatrists see so many people with co-morbidities that they have even created new categories to account for some of them.
The classic Kraepelian theoretical division between schizophrenia and bipolar disorder, for example, has long been bridged by a pragmatic hybrid called schizoaffective disorder, which describes those with symptoms of both disorders and was recognized in DSM–IV.

Ironically, the ingrained category approach is actually inhibiting the scientific research that could refine diagnoses, in part because funding agencies have often favoured studies that fit the standard diagnostic groups.
“Until a few years ago we simply would not have been able to get a gra nt to study psychoses,” says Nick Craddock, who works at the Medical Research Council Centre for Neuropsychiatric Genetics and Genomics at Cardiff University, UK.
“Researchers studied bipolar disorder or they studied schizophrenia. It was unthinkable to study them together.”

“Introducing a botched dimensional system prematurely into DSM-5 may have the negative effect of poisoning the well for their future acceptance by clinicians,” wrote Allen Frances, emeritus professor of psychiatry at Duke University in Durham, North Carolina, in an article in the British Journal of Psychiatry

The controversial personality-disorder dimensions were voted down by the APA’s board of trustees at the final planning meeting in December 2012.

The APA claims that the final version of DSM-5 is a significant advance on the previous edition and that it uses a combination of category and dimensional diagnoses.
The previously separate categories of substance abuse and substance dependence are merged into the new diagnosis of substance-use disorder.

Bodurka’s group is studying the idea that dysfunctional brain circuits trigger the release of inflammatory cytokines and that these drive anhedonia by suppressing motivation and pleasure.
The scientists plan to probe these links using analyses of gene expression and brain scans. In theory, if this or other mechanisms of anhedonia could be identified, patients could be tested for them and treated, whether they have a DSM diagnosis or not.

On the question of dimensionality, most outsiders see it as largely the same as DSM-IV. Kupfer and Regier say that much of the work on dimensionality that did not make the final cut is included in the section of the manual intended to provoke further discussion and research.

All involved agree on one thing.
Their role model now is not Freud or Kraepelin, but the genetic revolution taking place in oncology.
Here, researchers and physicians are starting to classify and treat cancers on the basis of a tumour’s detailed genetic profile rather than the part of the body in which it grows.
Those in the psychiatric field say that genetics and brain imaging could do the same for diagnoses in mental health.

Is Emotional Pain Necessary?

Is Emotional Pain Necessary?
August 02, 2010

bereavement exclusion

As Holly Prigerson, a researcher at Harvard University who studies bereavement says, “What underlies a lot of this discussion is: Is it harmful to interrupt a normal grief process by medicating?” Medicalizing Our Experiences But for some people, the real issue raised by the bereavement exclusion is philosophical — or maybe the better word is existential. Dr. Allen Frances, the famous psychiatrist and a former editor of the DSM, says that more and more, psychiatry is medicalizing our experiences. That is, it is turning emotions that are perfectly normal into something pathological. “Over the course of time, we’ve become looser in applying the term ‘mental disorder’ to the expectable aches and pains and sufferings of everyday life,” Frances says. “And always, we think about a medication treatment for each and every problem.” From Frances’ perspective, if you can’t feel intense emotional pain in the wake of the death of your child without it being categorized as a mental disorder, then when in the course of human experience are you allowed to feel intense emotional pain for more than two weeks?

see also:

The Power of Mindfulness: What You Practice Grows Stronger
Shauna Shapiro
cortical thickening
I’m not good enough


In Defense of Sadness: Happiness Is Overrated
February 14, 2008
depressive realism
[2nd part is better]

you can’t measure suffering

8:10 todos aquellos síntomas de despersonalización, de disociación, de embotamiento emocional que lo hemos dicho, pero de mucho retraimiento, que la persona se encierra en sí misma y no es capaz de salir de ahí, personas que por ejemplo padres o madres que no son capaces de cuidar de sus hijos, y ya no de cuidar a sus hijos sino de cuidar de ellos mismos, personas que dejan de comer, personas que dejan de llevar una vida … no normal porque ya hemos visto que esto es un proceso, que se tiene que ir normalizando nuestra vida, pero que vemos como que paran. Que dejan de vivir.
V3_5 Patrones básicos de reacción de los adultos tras los incidentes críticos

7:30 …a la vida normal lo mas pronto posible
V3_6 Factores protectores y de riesgo en emergencias cotidianas en adultos

Primeros Auxilios Psicológicos
Universidad Autónoma de Barcelona.

Does ‘Psychiatry’s Bible’ Need to Be Rewritten?

Does ‘Psychiatry’s Bible’ Need to Be Rewritten?
22 May 2013

Frank Farley, Ph.D from Institute of Psychiatry, University of London, England, is former President of the American Psychological Association and the Society for Humanistic Psychology

William W. Eaton, PhD, serves as Sylvia and Harold Halpert Professor and Chair of the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health.

Allen Frances was the chairperson of the DSM-IV Task Force, a former chair of the Department of Psychiatry and Behavioral Science at Duke University School of Medicine, and is the author of two new books: Saving Normal and Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5. Author of “Saving Normal”

neuropsychiatric disorders

Farley: the negatives now outweight the positives. It’s beyond fixing. There won’t be a DSM-VI.
It’s time to re-think the whole concept of diagnosis … break out of the biomedical model and include bio-psycho-social cultural model. DSM has run out of juice. We need fresh thinking on diagnosis.

Frances: DSM is good, actually wonderful is used well. It could be horribly harmful if …
Once the words are written, they take on a life of their own, and the drug companies have such tremendous marketing power that they’ve shanghaied the DSM and they’ve succeeded in convincing people that the problems of everyday life are really mental disorders due to a chemical imbalance, treatable by a pill.
So we have a remarkable degree of diagnostic inflation.
1/4 of the population now qualifies for mental disorder
1/5 people now take a psychiatric medicine.
This is out of hand. It has to be controlled. DSM-5 will make all this much worse by turning diagnostic inflation into hyper-inflation.
However, DSM-5 is enormously useful at diagnosing people who have clear-cut, severe psychiatric disorders.
There is no substitute for DSM-IV or DSM-5. I wish there was.
05:35 … Frances’ promise of a psycho-social model would be very useful if it could be delivered.

we have 1 million psychiatric patients in prisons because they’re not receiving adequate care in the community and a decent place to live

If they were diagnosed accurately and treated effectively, it would be a better world.

So the attack shouldn’t be if DSM is good or bad, it shoudl be how do we get a mental health system because right now we don’t have one.

Farley: Right now, we need to put DSM on a diet, right? It’s gotta be slimmed down, and targeted, and more precise

Frances: and we have to stop the drug companies from having the right to market

Eaton: We are the only country in the world that permits DTC advertising of medical products

DTC advertising: selective serotonin reuptake inhibitors
07:29 Prisons are now the mental hospitals of the 19th century. They have replaced …
50% of the people in prisons have severe or important mental illnesses

08:00 Book:
Bad Pharma: How drug companies mislead doctors and harm patients
by Ben Goldacre

Frances: psychiatry does as well as other medical specialties if it’s limited to its proper competence but if you take people with milder problems that more often than not really aren’t psychiatric disorders the placebo response rate is over 50% and medication is for the most part not helpful and very often quite harmful, and always expensive.

Farley: Asperger syndrome: the services will be restricted and it will be harder to get services
-> educational and familial implications of this change.

Frances: DSM was never created to determine school services DSM is a clinical manual, with clinical purposes.
We need to de-couple the educational decisions from a manual that really wasn’t developed to help make them

Eaton: biology and genetics, BUT the causes of mental disorder that we know are actually social

Farley: that fits into the bio-psycho-social-cultural model, which is an elusive model for sure, but one that I think we need to pursue because the reductionist model by NIMH just failed and they’re pushing hard for lab-based tests … nature and nurture are both involved.

Frances: the NIMH made a terrible error in overselling its overselling its hability to contribute to a diagnostic system.
The decade of the brain in the 1990’s revealed a tremendous amount of fascinating neuroscience but yielded nothing that was useful for clinical science.
The brain is the most complicated thing in the universe and its secrets are revealed only very, very slowly.
It will be a long time before we understand the causes fo mental illness on a biological basis.
We meanwhile need to be treating patients.
psycho-social models are absolutely crucial to understand mental illness but we don’t have at this point a psycho-social model of diagnosis

“Paradigm shif for the future”: fine, current psychiatric patients have desperate needs which are not being met


80% of the medication prescribed is done by non-psychiatrists (primary care doctors) after brief visits (7 minutes)

We now have more overdoses from prescription drugs that from street drugs


You should never accept the diagnoses after 7 minutes with the doctor.

Most people that go to a primary care doctor and get a medication will get better on their own. The placebo response rate is enormous. People are resilient. Life changes, people get better.

Frecuent OVERUSE OF MEDICATIONS but … you’re probably being UNDERTREATED.

EATON: The worst problem is not DSM. It’s DTC advertising.

FARLEY: psychotherapy works. Talk therapy works by and large. The particular method of psychotherapy doesn’t really matter all that much. Wheather it’s psychoanalysis or dynamic approach, or cognitive behavioral approach, etc.

Recognition of Psychotherapy Effectiveness
American Psychological Association.
Psychotherapy. 2013, Vol. 50, No. 1, 102–109

EATON: Global Health Unit: Interpersonal therapies, psychotherapies, cognitive behavioral therapies, trauma-focused behavioral therapies …

you can teach people with a high school education in a relatively short time to give a therapy which is effective


Insurance companies: they take a very short-term view of what is more expensive this year, worried that they won’t have that client for the longer haul

Psychotherapy is just as effective, perhaps more effective, with fewer side effects for mild-to-moderate problems. It doesn’t work well alone for severe problems.

psychotherapy lasts, whereas drugs have to be taken often for a lifetime

Psychiatry now = pill-dispensing

Eaton: “NIMH would say: we need to make VALID diagnoses”
The use of the term VALID for diagnoses is not quite appropriate.
Validity is for measures, not for diagnoses.
We don’t have that kind of VALIDITY in psychiatry, and it’s possible we will never have.


The concept of validity concerns the degree to which a measurement or study reaches a correct conclusion. A measurement or study may lead to an incorrect (invalid) conclusion because of the effects of bias. The variability seen with bias is systematic or nonrandom and distorts the estimated effect. In Figure 10–1, the amount of bias can be determined by the degree to which the shots are off target in D. Unfortunately, in medical research the truth (bull’s-eye) may not be known, or there may be no “gold standard” for comparison. Consequently, the degree of bias often is difficult to determine. There are two different types of validity, internal validity and external validity.
Medical Epidemiology, 4e © 2005 (Raymond S. Greenberg, et al) > Chapter 10. Variability & Bias


DSM categories and dimensions in clinical and research contexts
Int. J. Methods Psychiatr. Res. 16(S1): S8–S15 (2007)
Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA

The Power of Introverts in a World That Can’t Stop Talking

DSM-5 in Distress

DSM-5 in Distress
The DSM’s impact on mental health practice and research
December 2, 2012
by Allen Frances, M.D.

removal of the multiaxial system in DSM-5
September 20, 2013


Grief exclusion
By Kenneth S. Kendler, M.D.
Member, DSM-5 Mood Disorder Work Group

Validity of the bereavement exclusion to major depression: does the empirical evidence support the proposal to eliminate the exclusion in DSM-5?
World Psychiatry. 2012 Feb; 11(1): 3–10.

Major Depressive Disorder and the “Bereavement Exclusion”
May 15, 2013

The DSM-5 debate over the bereavement exclusion: psychiatric diagnosis and the future of empirically supported treatment.
Clin Psychol Rev. 2013 Nov;33(7):825-45.
Wakefield JC

Following the development of ICD-11 through World Psychiatry (and other sources)
World Psychiatry. 2014 Feb; 13(1): 102–104.
Valeria Del Vecchio

Proposals for ICD-11: a report for WPA membership
World Psychiatry. 2014 Jun; 13(2): 206–208.
Mario Luciano

DSM-5 Alternate Edition

Understanding the DSM-5: What every teacher needs to know
Greg Neimeyer, PhD, APA
American Psychological Association, 2014