DSM-5: will everyday worries be medicalised into Generalized Anxiety Disorder?

// 16 April 2011

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DSM-5 coverOver the past three years I’ve written at length about the likely impact on TS/TG people of the revisions proposed for the forthcoming fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Although the DSM originates in the US, it is internationally recognised and the criteria it uses to categorise many medical conditions are generally adhered to worldwide. And although it is far from perfect, it also formalises access to medical services, including GPs, therapists, medication and surgery. For example, the comparatively few rights and protections that exist for people diagnosed as having Gender Identity Disorder (GID) are there mainly because they are in the DSM.

But the proposed revisions aren’t limited to the area of gender identity; far from it. From Adjustment Disorders to Eating Disorders, Mood Disorders to Substance-Related Disorders, there’s a wide range of medical conditions under review. Included in this list of categories is Generalized Anxiety Disorder, which Bruce Jancin has written about at Family Practice News. Mr Jancin suggests that the proposed changes could have a much wider impact than is perhaps realised:

Generalized anxiety disorder, already the most common of the anxiety disorders, could double in prevalence in clinical practice with adoption of changes now under consideration for the coming edition of psychiatry’s diagnostic and statistical manual, the DSM-5.

His basis for saying this is that there are two aspects of the DSM-5 proposal that would lower the threshold for the diagnosis. First, there is a reduction in the required duration of anxiety symptoms from the DSM-IV’s 6 months to just 3 months and second, the number of required associated symptoms would be only 1 out of 4, rather than the more stringent DSM-IV criterion of 3 out of 6.

Other changes under consideration include deleting sleep disturbances and irritability from the list of associated symptoms on the grounds that they are insufficiently specific. The work group also is weighing reintroduction of dimensional attributes such as anxiety and depression to serve as adjuncts to the current categorical attributes.

“If there’s any psychiatric diagnosis where a dimension is relevant, it’s GAD, where some social animals – and not only humans – are just born with a greater propensity to manifest anxiety in response to normal stimuli,” [Dr. Alan J. Gelenberg of the department of psychiatry at Pennsylvania State University] observed.

Commenting on Bruce Jancin’s article at Psychiatric Times, Allen Frances MD points out where this might lead in reality – and it makes disturbing reading:

Why is this such a bad idea? The symptoms of GAD are extremely nonspecific and very common in the general population. They merge imperceptibly into the expectable worries of every day life and the normal reactions to common stressors. There are simply no bright lines separating someone who has a real mental disorder from the normal worry wart or the person with a lot of problems that actually do need worrying about. Any rapid expansion of the diagnosis of GAD will surely capture many of these false positive individuals who do not have clinically significant symptoms that require mental health diagnosis or treatment– people who would be better off left alone without further intervention.

But the way the world works, most people who get mislabelled will likely wind up receiving medication– usually antidepressants, and sometimes the much more problematic antianxiety drugs. Mild anxiety symptoms have a very high placebo response rate (around 50%)–quite close to the response rate achieved by medication. Although the majority of patients mislabelled as having GAD will not actually need medication, they will often receive it and may feel compelled to stay on it for the long term– with all the attendant unnecessary side effects, complications, cost, and stigma.

The thing to remember that there is not a pill for every worry or life problem and that pills can sometimes make things worse. Of note, DSM-5 is also suggesting another related change that will lead to even greater diagnostic inflation–a new disorder mixing common symptoms of anxiety and depression and requiring a remarkably short duration of only 2 weeks. Taken together, the 2 changes would capture a large segment of the worried well.

But it’s the closing paragraph which resonates most strongly with me, given what I’ve seen of the way the Sexual and Gender Identity Disorders Work Group under the aegis of Ken Zucker has approached its task:

In the preparation of DSM-5, the experts on the work groups have been given far too much freedom and far too little supervision. Their suggestions for changes are supported by cursory and one sided reviews that seize on the occasional study and ignore all that is unknown or contrary. Suggested changes should have been subjected to the much more stringent standards of evidence based medicine as applied by independent reviewers. The DSM-5 field trials should have been designed specifically to study the crucial question of impact on rates, not the fairly trivial question of reliability. A searching risk/benefit analysis needs to be done on each suggestion.

What is clearly broke and cries out for fixing is the DSM-5 process itself.

I can’t help but agree with that commentary – labelling the “worried well” as “disordered” seems to me to be blatant pathologisation and, if my own experience is any guide, I would expect such a labelling to lead to social stigmatisation from many perhaps unexpected quarters. However, given that field trials to test the new diagnostic criteria have now been underway since December 2010, I for one am not optimistic about the chances of a wholescale overhaul of any of the proposals for any of the categories ahead of the full publication of the DSM-5 in May 2013.

Comments From You

angercanbepower // Posted 16 April 2011 at 3:46 pm

It seems to me that a lot of the backlash against pathologisation is in itself pathologisation. E.g. from the article you quoted,

There are simply no bright lines separating someone who has a real mental disorder from the normal worry wart or the person with a lot of problems

What is a “real mental disorder”? There’s never going to be a “bright line” there, either. With anxious and depressive disorders it is a difference of degree, not nature, that separates the “normal” from the pathological.

The idea that there are people with “real mental disorders” and then everyone else, and that it’s terribly dangerous to mistake the latter for the former is inherently stigmatising as it presents people with mental ill-health as the “other”.

There are always going to be levels of anxiety which are considered normal which are close to mental illness because, *for a lot of people a lot of the time, being ill is not actually that different from being well.*

I welcome anything which moves society closer to accepting this.

Beth // Posted 16 April 2011 at 4:20 pm

Hmmmm. Speaking as someone who has GAD tendencies at the best of times and has ended up with full-blown GAD after a traumatic second trimester miscarriage and subsequent pregnancy [although the symptoms are easing up again now thank goodness], I’m not convinced that numerous people are going to end up on drugs as a result of this. Yes I had an experience that caused my problems to get extremely bad (and nearly ended up also suffering from OCD; more luck than anything else that I didn’t), I was offered a great deal of support from my GP surgery, but I was only offered ADs as a ‘you may want to consider them if thing don’t improve in the long run’ option. I ended up asking for psychotherapy with CBT and asking for the ADs, but at no time was I pressed to accept them – even though if I had done earlier the amount of NHS time I was taking up would have dropped significantly :/

HOWEVER – I do believe that my GP surgery is one of the best in the entire UK (twice I’ve had a GP turn up at my door to make sure I was OK because they were concerned about me without me asking for a home visit) and I do accept that the excellent service I have had will not be the same everywhere.

And, full disclosure: I’d be a lot more worried about it if I lived in the US.

Carrie // Posted 16 April 2011 at 7:57 pm

Helen, a very well written and thought provoking article. I do wonder if the changes to GAD under DSM-V are a by-product of where mental health practitioners has been tending towards for years. All manner of anxieties seem to be candidates for treatment by prescription, without sufficient investment in therapies based around emotional development and support. It seems to me that greater pathologisation will in fact itself, lead to greater pathologisation.

Treatment by tablet remains economically, a much more attractive choice. I fear access to non medicated therapies will only diminish, except in the most acute of cases. Scary stuff frankly.

Jennifer Drew // Posted 17 April 2011 at 11:09 am

The DSM manual is a deeply flawed but continues to be perceived as the default manual in respect of male-centric definitions of women’s psychiatric disorders. I’m waiting for the psychiatric disorder ‘male hatred of women’ to be included given this disorder is not natural but is in fact a mental disorder.

Generalised anxiety disorder is a sweeping term which can and will be used to maintain white male medical control over predominantly women’s lives. It is deliberately not specific and so we have to ask why? Who will benefit from this latest new invention? Will it be women or will it once again be men – given males are the default humans. Remember medical science is never objective but constantly changes in line with cultural changes and the tiny gains women have struggled for centuries to achieve. Medical science is all too commonly a tool of male supremacy and hence cannot be viewed as ‘objective.’

But no worries the huge multi-national pharmaceutical industries will create new and even more dangerous drugs to combat this new disorder! Women will be given these dangerous drugs and Big Pharma will continue to profit by controlling women’s lives.

Dr. Paula Caplan has direct experience of challenging the white male-centric perspective which operates every time the DSM is revised. Below is link to her website which provides details of how psychiatric disorders are used to maintain control over primarily women and some men who dare to challenge male supremacy and male power. Male control over women is behind the DSM and one need not look too hard to locate the evidence. Jane Ussher has written about how male medical establishment pathologises women.

http://psychdiagnosis.net/

Do not be confused by the medical claim ‘generalised anxiety disorder’ and other psychological illnesses which do exist. The first is a generalisation with no definition of precisely what supposedly amounts to a ‘disorder’ compared with say ‘clinical depression’ but even then that is commonly used by male medical establisment to maintain its power and control over women.

The medical establishment is never objective because they cannot eliminate their cultural conditioning with regards to notions of supposedly ‘female and male appropriate behaviour.’

Beth // Posted 18 April 2011 at 8:26 am

angercanbepower – that’s a really interesting comment. Every time I mention anything about my therapy to my mum she sounds worried – I told her last night about a pattern my therapist had identified (which I think is spot on and I’m glad I know about because now I can start to change my behaviour) and she immediately started telling me not to believe that that was what I was doing! She’s only concerned about me, but doesn’t like to think of me having any kind of mental disorder, no matter how mild – which is understandable but I think the idea that there are *normal people* and *mentally ill people* and never the twain shall meet plays into her fears of hearing me talk about such things.

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