We need to talk about the DSM

[ArabellaScott]

The DSM is effectively used as the 'bible' for treating mental health issues.

I'd.always assumed it was a compendium based on masses of rigorous research and represented the settled consensus of the whole corpus of medics, psychologists, psychiatrists, etc.

This man claims that it is effectively the consensus of a tiny group of people and based often on little or no research at all.

This seems a very important watch, for all sorts of reasons.

The presenter mentions one disorder in particular ' self defeating disorder' that was argued was liable to be used against women victims of dv.

Also touches on the explosion of diagnoses of autism.

And gender issues are implicated.

I urge a watch:

Another good quote

The medical model had taught me everything about being ill, and almost nothing about being a healthy, well-adjusted grownup, who has a sense of agency

@Delphinium20 there's also a researcher at oxbridge looking into similar things. Will go hunting.

Well not quite but within the realms of the discussion:

Adolescence is a period of identity development for everyone. Like many teenagers, I was introspective and ruminative. My friends and I dissected our personalities, thoughts and behaviours all the time. If I had repeatedly been offered the word “anxiety”, without any decent one-to-one treatment, I think it would have been cemented into my self-concept before I had even turned 13.

https://www.theguardian.com/commentisfree/2023/jul/09/psychologist-anxiety-personality-trait-children-sick?CMP=ShareiOSAppp_Other

There is also the question of what counts as a "disorder" or disease. With psychiatric disorders there seems to be a particular tendency for lines to move.

While it's not unheard of in conventional medicine for a disease to be defined on the basis if a group of symptoms, without understanding it's cause or genesis, it seems to be extremely common with psychiatry. When many times the presentation of symptoms can seem to vary depending on things like your culture - it's not objective, but socially conditioned. Is body dysmorphia a disease, or a symptom of something else? What is the cause - is that the real disease? Is it even one thing? Who knows!

Normally though we only diagnose disease where there is an effect, an illness. You can have flu virus in your body, or strep, but you do not "have" flu or strep unless you are sick. Having feelings of body alienation is normal in teenagers - so can we really say they are body dysmorphic? This also seems to be a common kind of problem in psychiatry.

Lucy Foulks is a really interesting follow on Twitter; she's very nuanced.

She's has been sharing evidence that counters Jonathan Hait's theories about smartphones. It's not a binary cut and dried fact that the rise in MH is due to smartphones. Though they undoubtedly don't help

I've come to think that sending kids to therapy for things like anxiety in a lot of cases makes it worse. It doesn't require special care to help most teens break down things that scare them and face them step by step.

Therapy does make a mental illness worse at first. That’s why you have to be stable enough to start it, because the start can make you worse while you work through your issues. In the long run, therapy improves your mental health and can reduce risk of major relapses, or an accumulation that then leads to more serious illness.

I largely agree but with the clear exception of your last point. There have been concerted efforts for decades to discover biological markers for MH conditions. The undertaking has been huge and an abysmal failure despite the wealth of big pharma thrown at it. And highly odd as although we only have unclear and uncertain physical diagnostics for a good many physical conditions, plenty more have been elucidated opening up therapeutic channels. Not the case for psychiatric diseases.

You are correct that Laing was definitely a significant figure in the critical psychiatry movement.

The wikipedia page here is a good foundation to start to learn more, it is about the UK based CPN.
https://en.wikipedia.org/wiki/Critical_Psychiatry_Network

I am very far from an expert in it and mostly know of mostly it in relation to studying the intersection of cults and pseudoscience / quackery in mental health services, at which point distinct networks of academics and mental health professionals (some more professional than others) become apparent.

An important way of thinking about this issue, I believe, is in relation to ideas about “punching up” and intersectional movements relating to the complexity of oppression.

For example; You may support the rights and protections of gender nonconforming people but not believe that people can change sex.

You might believe that children have rights and should be listened to, but not agree that 12 years olds can vote in elections, that children can consent to sex with adults or that 4 year olds can identify as the opposite sex.

You may reasonably conclude that people with serious ongoing mental health issues can have a voice re the commissioning of mental health services, but not agree with a situation in which seriously mentally unwell people, whose grasp on reality is severely compromised, take a significant lead in the commissioning of mental health services (unfortunately this latter case is happening now in some parts of the UK).

It seems to me that the critical psychiatry movement may have important things to say but that it has been astroturfed and is being used as a Trojan horse by various revolutionary activists who do not have the interests of the UK or mentally ill people at heart.

Whatever the critical psychiatry movement may have been at one point, it is now a very different beast indeed.

I am not suggesting that all is fine and dandy in psychiatry land, far from it. I would very much like there to be more options than those of organic psychiatry on one hand and the shabby collection of occultists, new agers and assorted revolutionaries that the critical psychiatry movement has become on the other.

I don't think anxiety in teens is usually a mental illness. I think treating it as if it is can turn it into something much worse.

Exceptions occur of course. But a lot of feelings are normal in adolescence and the last thing kids need is to be told they have a mental illness that means they have something wrong with their brain.

So what should kids be told? It’s normal, everyone feels that way (when they don’t) after minimising it, you tell them what to suck it up? Suppress the feelings? Or this one ‘feel the fear and do it anyway’

You know that usually leads to breakdown/burnout years down the road.

So for want of a bit of therapy on how to live with and manage anxiety given to a teenager, you up the risk of it derailing their adult lives by leaving it untreated and festering.

'feel the fear and do it anyway' could very plausibly be applied to cognitive behavioural methods of anxiety treatment, to be honest.

And you're making a lot of unevidenced assertions, SummerFeverVenice.

You tell them it's normal for teens to have heightened emotions, why, and you help them learn to manage their feelings. To some extent that does mean sucking it up a bit - exposure is an important part of coming to understand that even when something feels scary, the reality is that most of the time, the scary thing is manageable and the bad outcomes we are envisioning are largely in our own mind. It is possible to be brave - but that is a learned thing and can only be learned through experience.

That does not actually require a therapist. And I am sorry to say that I haven't seen particularly good results from kids going to therapy for this kind of problem, and while that's obviously anecdotal, I don't think the research paints a more positive picture. All these kids in therapy are not coming out healthier.

And yet in the last few days a mother whose 11 or 12-year-old daughter expressed some anxiety about being left alone in the family home, in daylight, for 15 minutes, was accused of neglect and being a cruel, damaging mother for even contemplating leaving her and, in so doing, encouraging her to overcome her fears.

If the women criticising the OP weren't trolls, or weren't engaged in a mass wind-up, then we have a whole new generation of incapable, anxious, kids to come. Children who've never been expected to feel the fear and overcome it.
https://www.mumsnet.com/talk/am_i_being_unreasonable/5068035-to-think-its-not-cruel-to-take-dd-to-the-gym-at-730am?page=40&reply=135059626

My Nordic farmer upbringing taught me that lot of parenting of a child who is utterly distressed and scared to do something is telling them to get over themselves and do it anyway, all while being a stable adult in their lives. I've had a very anxious child and a fearless child (who also ended up being scared of specific things later in life, but then had to overcome them as well), and I have to say, there's a lot of wisdom in that as long as there's no abuse.

When a school counselor told us anxious child might have low-grade anxiety disorder, we took it seriously, but not serious enough to get medication. I also didn't have good insurance then so couldn't afford therapy, so decided to ride it out until I did. Something also told me that the therapy would need to be mostly behavioral so I should just do that myself...which I did. Giving her some absolutes, things she had to do, and being patient as she worked through the stress of doing them, like having awful stage fright, but still needing to perform. As puberty came, then teen years, I realized something...my DD didn't need therapy, she wound never need meds, she just needed coping mechanisms and my DH and I were already teaching that. And, these coping mechanisms have given her confidence I never would have imagined could be so strong. It's the overcoming of the challenge that gives us strength, not the avoidance.

Of course, this is merely one personal anecdote, but, coming out of that, I realize that our experience could have turned into a lifelong prescription management thing, it could have also told our daughter something was wrong with her. I feel like we narrowly escaped the bad therapy Abigail Shrier wrote about recently.

*I don't think anxiety in teens is usually a mental illness. I think treating it as if it is can turn it into something much worse.

Exceptions occur of course. But a lot of feelings are normal in adolescence and the last thing kids need is to be told they have a mental illness that means they have something wrong with their brain.*

To be honest I’d say the same about most anxiety in adulthood. The difficulty is often that in the absence of understanding that anxiety is a normal human emotion, and how to cope with that emotion, people can spiral to where they become anxious about feeling anxious which in turn can become very limiting.

It’s also my experience that people (teens and adults) usually have something concrete underlying the anxiety that they’ve dismissed or disregarded. That may be normal human development and hormones, a bereavement, something traumatic they’ve pushed down etc but I can’t think of anyone I’ve worked with where there wasn’t something underlying what feels like “general” anxiety.

Therapy can be helpful in giving a neutral space to get to the underlying “thing”, give coping strategies etc, it’s not helpful to give label after label. A good therapist should be able to help contain anxious feelings and help with reframing challenges. They should also have a good understanding of social contagion and its role in mental ill health, particularly in young people.

Some parents are able to hold their kids steady when they are anxious, some aren’t.

I think the entire thread is “unevidenced assertions”
Its less robust debate, more light conversation

An anxiety disorder is not the same as feeling the normal emotion of anxiety. Exposure isn’t the answer when a teen or adult is experiencing high anxiety. For all the reading of the DSM and ICD on this thread, it is dangerous to dismiss all mental illnesses as “social constructs” and write post after post saying something like an anxiety disorder is not a real illness when it absolutely is.

This child was told her feelings were normal, to suck it up and just go to a two hour detention. She ran away from school to her mum’s house as a cry for help. She was simply taken back and was told the detention would go ahead anyway.

Hours before it started, she killed herself.

Sometimes being told their feelings are normal and to just suck it up is the last thing they will hear from you….ever.

“I hope this is my last diary entry. I want to kill myself tomorrow,” the entry, written the night before her death, is reported to have read.
Speaking of how the threat of detention had been playing on her mind, she writes: “Running away was the best cry out for help I could give and you [Wycombe] responded with ‘we’d normally punish you but you’re already getting punished’.”
Just hours before she had reportedly been due to receive a two-hour punishment, known as a “headmistress’s detention”, Caitlyn took her own life.
The 16-year, who was due to sit her GCSE examinations soon, was issued the punishment after vodka and a tattoo kit had been found in her locker before the Easter holidays.
“She was mortified to receive a detention,” Mr Scott-Lee, 41, told the newspaper.”
https://www.independent.co.uk/news/uk/home-news/caitlyn-scott-lee-wycombe-autism-b2329697.html

One issue is that if symptoms are the extreme end of a continuum, the application of a diagnosis leads to an arbitrary cut off point. If your body is invaded by measles virus causing symptoms, you have measles. If you're anxious you may be 'normal' or crossing the borderline into anxiety disorder.

No one has said that there aren't people who have extreme mental health issues requiring intervention.

Really? What was this gem then if not a wholesale denial of the existence of mental illness:
”Yup, all these labels are social constructs created by a small bunch of white male psychiatrists in the US. The DSM is hugely influential including to the ICD, and it helps it is given out free as sweeties by the drug companies. Dr Davies also does an excellent presentation on ADHD and the most prolific researcher into the diagnosis, a psychiatrist who has been payed millions by the drug companies to fund his research. What better way to make money that get kids diagnosed with a life long condition that needs medicating, ensure it's pushed on all the algorithms on social media and kerching, a lifetime of lucrative income! Someone get me some shares in big pharma!”

And really this post is only repeating the views of Dr Davis. The OP linked to a talk of his espousing these views and he is well known to have published books like “Sedated” essentially saying psychiatry and mental illness is all made up to create a profit making market due to neoliberal capitalism:
”Psychiatry is not a science, even though, of course, it aspires to make use of scientific findings to guide its practices (as to who often produces those ‘findings’ we’ll leave for another day…).”

”By using medical symbols like ‘disease’, ‘illness’, ‘disorder’, ‘pathology’, ‘diagnosis’ etc, the explanatory model drags diverse experiences of human suffering under the authoritative purview of its own jurisdiction; recasting suffering as an essentially medical problem that its own specialist knowledge and proficiency is uniquely positioned to treat.”

”So what are the main features of this collusion between neoliberalism and mental health? How has the sector been able to flourish despite its consistently poor results? Well, here are a few mechanisms I discuss in ‘Sedated’:

Firstly, our sector has depoliticised suffering: conceptualising suffering in ways that protect the current economy from criticism – i.e. reframing suffering as rooted in individual rather than social causes, thus favouring self over social and economic reform.

Secondly, it has privatised suffering: redefining individual ‘mental health’ in terms consistent with the goals of the economy. Here ‘health’ is characterised as comprising those feelings, values and behaviours (e.g. personal ambition, industriousness and positivity) that serve economic growth, increased productivity and cultural conformity, irrespective of whether they are actually good for the individual and the community.

Thirdly, it has widely pathologised suffering: turning behaviours and feelings deemed inconvenient from the standpoint of certain authorities (i.e. things that perturb and disrupt the established order), into pathologies that require medical framing and intervention.

Fourthly, it has commodified suffering: transfiguring suffering into a vibrant market opportunity; making it highly lucrative to big business as it manufactures its so-called solutions from which increased tax revenues, profits and higher share value can be extracted.

Finally, it has decollectivised suffering: dispersing our socially caused suffering into different self-residing dysfunctions, thereby diminishing the shared and collective experiences that have so often in the past been a vital spur for social change.”

I realise the conversation has moved on a bit but this lecture by Paul McHugh is very good. His timeline stops just before what we now know came next but which he in particular probably did not expect.

Abuses of the Public by Psychiatry

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(video should start after what seems like an interminable introduction by the host)
"The Fall 2010 Schmitt lecture was given by Dr. Paul McHugh, Johns Hopkins School of Public Health."

Yes, that Dr Paul McHugh:

Long shadow cast by psychiatrist on transgender issues finally recedes at Johns Hopkins
Washington Post - 2017

"Paul McHugh, the former chief of psychiatry at Johns Hopkins Hospital, helped to end Johns Hopkins’s pathbreaking transgender surgery program nearly 40 years ago."

https://archive.is/q9ax4

Thanks, Bosky. I hadn't heard of Hughes. Will.try and dig out that study.

Can't find a full copy available to read. Abstract here:

www.semanticscholar.org/paper/Sex-reassignment.-Follow-up.-Meyer-Reter/5e9ec3f107903ff1233104ee12510f4f6c715b76

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