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Are the 'normal' an endangered species?

March 20, 2014
by Nicholas A. Roes, PhD
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According to psychiatrist Allen Frances, MD, author of Saving Normal, more and more ordinary behavior is being pathologized, and there are no signs this trend will be reversed anytime soon. Abnormality constitutes such a growth industry that those who are defined as normal are very close to becoming a minority.

To illustrate by example, understanding the difference between sadness and depression used to be simple. Sadness was something we all experienced, and depression was a clinical condition that could be treated. Now, it’s not so simple, and 11% of our population—more than 1 in 10 people—is on an antidepressant.

“Diagnostic inflation,” as Frances calls it, has led to a situation where the threshold for a depression diagnosis has been lowered steadily. To make matters worse, those most in need of help often go untreated or undertreated.

The increase in antidepressant use has happened in part because patients have seen direct-to-consumer advertisements for the medications, and doctors have been accommodating their requests. So, instead of having antidepressants prescribed mostly by psychiatric specialists dealing with clinically depressed clients, most antidepressant prescriptions today are written by general practitioners.

Frances explains other factors that have contributed to diagnostic inflation. “Fads” get started because inclusion in the DSM gives any diagnosis legitimacy, he says. “Experts” seem to have a tendency to exaggerate the number of people affected by their area of specialty. And the media can create a near hysteria, leading to a false epidemic spreading like wildfire.

Resources stretched thin

More diagnosis is not always better. Frances points to the possible over-diagnosis of post-traumatic stress disorder (PTSD), in part because the diagnosis is required for veterans to access some needed services. But over-diagnosis also may create a stigma that extends to all veterans, making it harder for them to land jobs. Even worse, over-diagnosis of PTSD may distort allocations across the system, and reduce the pool of benefits for those who need them most.

Supporting this trend toward over-diagnosis is the pharmaceutical industry, with its worldwide sales now totaling more than $700 billion. Frances reports that “Big Pharma” spends twice as much on promotion as on research, and that the research is often shoddy. Seven percent of Americans are now addicted to a legal psychotropic medication.

Addiction is being affected

There is general agreement that substance use disorders are among the most under-diagnosed. But a similar diagnostic creep also is happening in the field of addictive disorders. Frances, who chaired the DSM-IV Task Force, sees a problem with the new “Non-Substance-Related Disorders” category in the Substance-Related and Addictive Disorders section of the DSM-5.

“The problem is that repetitive pleasure seeking—even if costly—is a part of human nature. Compulsive behavior that is not rewarding is relatively rare,” he says. “The danger is these behavioral addictions will expand from their narrowly intended usage to mislabel any fun that comes with a cost. Behavioral addictions are another great leap backwards, pushing mental disorder further into the ever-shrinking realm of normality.”

The concept of addiction comes with the idea of limited ability to control behavior. The fear is that behavioral addiction will expand to include many different kinds of irresponsible behavior, such as frivolous spending, extramarital sex, or a history of going off one’s diet.

Another serious concern involves the lumping together of substance abuse and substance dependence in the DSM-5. The two previously distinct diagnoses are combined into Substance Use Disorders in a section called “Addiction and Related Disorders”. This means abusers have been “promoted” to addicts, and the previously useful distinction between the two is no longer available to those using the DSM-5.

“All the DSM disorders overlap with one another and frequently with normality,” says Frances. “It’s both unwise and unfair to pin the pejorative and stigmatizing label ‘addict’ on someone whose problems are temporary. Most substance abusers are in a passing phase and never become addicted in any meaningful sense of the word.”

The current DSM offers no way to distinguish those for whom substance use plays a central, extremely harmful role in their lives from those who go on a recreational binge.

Companies that profit from the sale of addiction medicines are benefiting from this lack of clarity. Addiction treatment may go down the same path as treatment for depression, PTSD and other diagnoses—where those with few or no problems are medicated while those with the most serious problems don’t get the help they need. Addiction also is being treated less often by specialists and more often by general practitioners.

Large amounts of resources may be going to prescriptions for addiction medications for patients who wouldn’t even have qualified as dependent under the DSM-IV. As financial resources and attention shifts to those who are less in need of our care, those most in need may not get the services they deserve.

Addiction medications carefully matched to individualized treatment plans can be helpful. Addiction medications prescribed instead of individualized treatment by general practitioners may create more problems than they solve.

Is there anything we can do about all this? Frances thinks it will be difficult, but not impossible, to save psychiatry and to save normal.

“My rational self tells me that diagnostic inflation will win and that saving normal will lose,” he admits, “but every once in a while a scrawny David knocks off a powerful Goliath.”

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