Disorder Disorder, Ctd

A reader writes:

Allen Frances bemoaned, “About half of Americans already qualify for a mental disorder at some point in their lives.” Roughly 100% of Americans already “qualify for” a somatic disorder at some point in their lives.  Does that mean we have too many somatic disorders on the books?   Or does it mean the human body and its interaction with the physical environment is a highly complex system in which there are a lot of things that can go wrong? Consider how complex the brain is as an organ, and how complex the mind is, and how complex the interactions between those things and human culture are.  How many places and ways are there for a system that complex to malfunction?  And how far is our understanding of that system behind our understanding of the human body?   I’m not sure why anybody would be surprised that we’re finding a lot of new mental disorders.


As someone who seriously studied Foucault as an undergraduate philosophy major, its hard to believe I am about to make what amounts to a defense of the new DSM, but here it goes. One of the reasons some of the definitions have been expanded has to do with insurance reimbursement.

Insurance companies need a diagnosis in order to pay clinicians to treat individuals. This is even more important for low-income individuals, because there is a select set of disorders, referred to as “serious mental illness for which individuals can be eligible to receive treatment. It happens that major depressive disorder is one these illnesses. We also know that the loss of a loved one is an event that can trigger major depressive disorders in individuals who may have not show clinical symptoms prior to the loss. So hypothetically, with the old “bereavement exception” (experience clinical depression symptoms after the loss of a loved one), an individual who may be in serious need of help and cannot afford to pay out of pocket, would not be eligible for services under the old criteria.

Were the motivations to change the criteria primarily driven by concerns for the poor? Probably not. Under these new guidelines, pharmaceutical companies will certainly benefit from physicians prescribing anti-depressants for what has traditionally been understood as the normal grieving process. But I have trouble with people, especially clinicians, laying the blame at the foot of the APA and DSM. Like any diagnosis, the new guidelines are intended to be made by experienced professionals using clinical judgement. They are not meant to be read like a laundry list or a cookbook that is then juxtaposed on an individual.

No, gluttony is not “binge eating disorder” if it’s a conscious choice that you are okay with. But it is an issue if it causes you distress, feels uncontrollable, causes you to gain weight and could lead to a host of other physical and mental health issues. That is why most disorders come with the qualification that they cause distress and impair functioning.

But the larger point is dealing with how our society views mental illness. It seems that implicit in Dr. Frances’ post is the notion that somehow mental illnesses are reserved for the “other”. Sure, about one half of individuals qualify for a mental illness at some point. How many qualify for a physical illness? I am sure the number is much higher. It is true that physical illness is typically much easier to understand that the complexity of the brain and its interactions with the body, and not to mention other individuals and society as whole. But if that is the case, it seems that the more productive conversation is about how our understanding of the brain and mental illness is only emerging and if we think a medical model is appropriate for both capturing and treating human suffering in its various forms.