Disordering normal 5.0

Here comes the new DSM

DRUG BUST by Alan Cassels

• The people’s briefing note on prescription drugs

Towards the end of May, the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), the iconic bible of psychiatry, is coming off the presses after much revision and delay. It’s bound to keep people asking, “Am I normal or do I have a mental illness?”

If you think most diseases are established with objective criteria and rigorous debate, you’d be somewhat wrong. The DSM has a strong track record of taking clusters of symptoms and wrapping labels around them, which lead to the accelerated use of some of the most toxic medications on the planet. How does this happen?

The DSM is owned and operated by the American Psychiatric Association (APA), an organization that many feel is itself owned and operated by the pharmaceutical industry. Seventy percent of the authors of the DSM-V have declared ties to pharmaceutical manufacturers and in some disease categories it’s 100%. This is the bizarre situation we’ve shamelessly come to accept: Big Pharma is allowed to put their own people on the committees to define what is and isn’t illness.

Many people agree that the old DSM-IV has been responsible for widening disease definitions and accelerating the medicalization of many diseases such as autism, ADHD and bipolar disorder. The principle here is that the broader you define a disease, the more people can be defined as having it and the bigger the market for drugs for the condition. The new bible will have more disease labels constructed from personality quirks, mood upheavals, normal bouts with sadness or common signs of aging, inevitably leading to even more prescribing.

A new category of mental illness known as “mild cognitive impairment” is the first time the label of ‘pre-dementia’ will apply to whole populations. Let me ask (most gently) who among us is not ‘pre-demented? In addition to the worries around our aging tendency to forget names, words and where we put the keys, we now have a name for it. As one ad for Alzheimer’s medications asks, “Is it just forgetfulness? Or maybe it’s “Pre-Alzheimer’s?” What better way to get perfectly healthy people to start shuffling down the cattle ramp towards a good jolt of the yet-to-be-launched pre-dementia medicines that the drug industry will soon be zapping us with? There are none yet, but trust me; those drugs are in the pipeline.

Right now, there is no cure or treatment for Alzheimer’s disease and unfortunately the drugs that do exist are next to useless. They are promoted as “slowing the rate of decline,” but there is little evidence to support that claim and they make many patients miserable with vomiting and severe nausea. Alzheimer’s is devastating for families but no one can explain how much anyone would benefit from adding “pre-dementia” to the burgeoning list of categories of mental illness.

How about grieving? According to a recent medical journal article, about 280,000 Canadians die every year and many of us are deeply affected by the death of loved ones. We experience profound grief and, for some, dealing with loss is very difficult. But here’s the hitch: What used to be considered a normal response to loss is now in the gambit of being considered a mental disorder.

Psychiatrist Dr. Allen Frances, who led the creation of the DSM-IV and lists its many sins, says the new DSM-V is going to be a disaster on the bereavement issue, adding that changing the definition of what is considered depressed (by including bereavement) “inflates estimates of the current incidence of depression in epidemiological studies” and will automatically ramp up even more demands for medical services and antidepressant medication. Should people who experience severe grief be tossed a pill that will, in effect, eclipse the many social and familial ways we have of dealing with loss? The makers of the new DSM-V think so.

Another new definition in the DSM-V suggests that being worried about disease and searching for information about it on the Internet is now worthy of a mental diagnosis. Last December, Dr. Frances blogged on the Psychology Today website about the DSM-V, stating, “One in six people suffering from cancer, heart and other serious diseases risks being saddled with a psychiatric diagnosis just because they are worried about their illness or spending more time on the internet researching their symptoms than the American Psychiatric Association (APA) thinks good for them.”

Add the word ‘Cyberchondria’ to the list of new mental health diagnoses.

And since we’re in the game of naming pathologies that seem highly aberrant, maybe there are some that haven’t made it into the new DSM. I’m thinking specifically of the types of illnesses that seem prevalent in corporate environments and bureaucracies.

Last fall, there was a mass firing of staff at the BC Ministry of Health amid allegations of privacy breaches, conflicts of interest and inappropriate data access procedures. Nothing of this magnitude has ever happened in the provincial government, but because the Ministry is so tight-lipped about its prolonged investigation, we can only do what the psychiatrists do – suggest new disease categories based on observation and speculation.

Here’s the scene: After a long summer of interrogations and job suspensions, six employees at the BC Ministry of Health were fired and a seventh is suing for constructive dismissal. One is now dead and we don’t know why. A pile of drug safety evaluations were halted and no one can say what it is really all about. This is significant because usually your mental illness only hurts yourself and those close to you. But what if your mental illness hurts the people who work for you?

The fired Ministry employees, who were working on or evaluating drug safety in the province, were possibly ready to uncover problems with many commonly used drugs. The only credible explanation for the mass firings is that lobbyists for the pharmaceutical industry in BC were putting pressure on Ministry bureaucrats, thus creating pathologies worthy of inclusion in the DSM-V. Here are two possible candidates:

Bureaucratic anaphylaxis: Bureaucratic anaphylaxis is where a small allergen (a whiff of wrongdoing) sends the bureaucracy into paroxysms of power-wielding, Kafkaesque interrogations and seemingly random firings and no one in power is willing to explain anything. This behaviour may be due to the willingness of bureaucrats to allow Big Pharma to influence them in ways that seem rational to pharma’s investors, but perversely nutty to anyone else.

Career advancement disorder: There are a number of senior officials in the Ministry (I could name names, but I won’t for now) who, through all this, have exhibited an extreme careerism, blindly crushing others’ fingers as they climb the corporate ladder. These bureaucrats seem to exhibit indifference to the public’s concerns and feel that displacing people in the Ministry who do independent evaluations is justifiable because the orders came from above. Here’s one very popular speculation: The Ministry’s senior people probably believe they’ll be unemployed after the next election so in the name of career advancement they’re carrying out a scorched-earth policy to please their buddies at Pharma should they find themselves out of jobs. This scandal reveals a highly politicized environment in the health bureaucracy where no one speaks out against injustice, stupidity and bureaucratic anaphylaxis and where the orders of your bosses, no matter how bizarre, counter-productive or illegitimate, must be followed.

Let me dedicate this column to Stanley Milgram, the obedience researcher who showed how extreme obedience is in itself a serious mental pathology that is alive and well in many of today’s hierarchies. Even in sunny Victoria. As I said, for disease-watchers this is going to be a banner year.

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Alan Cassels is the author of Seeking Sickness: Medical Screening and the Misguided Hunt for Disease. Follow him on Twitter @AKECassels or www.alancassels.com