Culture and DSM

What is the dominant model of mental illness?

Psychiatry - a medical based model that treats mental occurrences or conditions as discrete, diagnosable disorders that require intervention

What is a key difference between physical illness and mental illness?

We have biomarkers for medical conditions—we don’t have objective biomarkers for mental disorders.

What is the key issue with diagnoses? (3)

• They become reified, i.e., they are treating an abstract, dynamic concept as if it is a real, concrete entity.

• I.e., diagnoses are treated as concrete, actual phenomena

• In reality they are classifications/typologies based on constellations of symptoms, with often arbitrary cut-offs for when those constellations become “disorders”

What did Emil Kraeplin assume about courses of mental disorders? How does this apply to SD?

• That they followed a medical model where the symptoms and disorder predicted a uniform course.

• With SD, it was assumed that it resulted in irreversible deterioration

• Now, the symptoms associated with this course are known as negative symptoms

• We know there are three different courses of SD

What are the three different courses of SD?

• 1/3 Fully recover and are not seen in such clinical settings again

• 1/3 have episodic relapses

• 1/3 will never recover

What of Emil Kraeplin remains in the DSM? (3)

• There is still differentiation between disease entities (“Is it A or B?”)

• All versions of the DSM follow a descriptive, categorical approach as outlined by Kraeplin

• The observation of symptoms provides evidence of illness

What is an issue with Kraeplin’s descriptive, categorical approach with differentiation between conditions? (3)

Co-morbidities (anxiety + depression) are a rule, not an exception

Rarely will someone have just one presentation, even in categories of disorders (i.e., rarely will someone have only one anxiety disorder)

While specific symptoms can be unique to certain disorders, generally all disorders in a category follow an underlying pattern

While delusions exist across time, they can change how?

Content can change to reflect culture and what is going on with our lives.

For instance, 150 years ago, delusions surrounded religion and demons. In the 70s, KGB and aliens. Now, technology and surveillance.

What can we understand symptoms as? What is one caveat to this? (according to Karl Jaspers)

A reflection of life — something that arises meaningfully from a person’s personality, life history.

• Sometimes symptoms come up that cannot be understood in this context

• In this case, biological causes may explain it.

What are key aspects of delusions, according to Jaspers? (3) How does this align with culture?

• Held with conviction

• Resistant to counter arguments

• bizarre or impossible content

• An idea being outside of the culture is more likely to get tagged as a false belief, while an idea being culturally congruent means it won’t be tagged as a delusion

What is the irony of Jaspers’ work?

He attempted to introduce a role for psychological explanations in psychiatry, but gave psychosis to biologists and isolated his research from psychologists, preventing psychological investigation of psychosis

Schneider believed what was more important?

Paying attention to form rather than content. This is still the dominant model of psychosis and most mental illnesses.

What is the Great Classification Crisis?

Science begins, and then a paradigm is presented. Once that paradigm is accepted, researchers work within that paradigm, eventually producing observations that cannot be fitted into the existing paradigm. Then, a new paradigm is presented, and the cycle repeats

AKA, Paradigm presented → Paradigm accepted → Paradigm used → Contradicting evidence → New paradigm presented

What is Kraeplin’s legacy? (3)

• All versions of DSM follow a descriptive, categorical approach as outlined by Kraeplin

• Observation of symptoms provides evidence of illness

• Clinicians still try to differentiate between disease entities

What is a problem with the categorical rather than dimensional approach to psychopathology?

• When there’s a lot of criteria, there’s a lot of ways to get a diagnosis, meaning those with the diagnosis are not a homogenous group of people

• People can meet 4 really impairing criteria and not reach diagnostic threshold, as opposed to someone who meets more criteria to a less impairing extent

What are tests a diagnostic system must pass to be useful, and how is this at odds with the discrete disorders listed in the DSM?

• They need to be reliable

• Numerous studies in the mid 50’s show poor agreement amongst clinicians

How are the European (ICD-11, WHO) and American models of mental illness different?

• ICD-11 has shifted to a more dimensional approach

• British concepts tend to be broader

How was the DSM-III influenced by industrialisation and culture? (4)

Political concerns about homosexuality influenced its inclusion as a disorder rather than normal human variation

Overpathologising of human variations and experience, largely due to monetisation and its influence on treatment availability

Emphasis on diagnoses being needed for insurance to compensate

Movement towards a more biological approach to psychiatry.

What is the Feighner criteria? What is a key problem with this?

• For each disorder, a precise list of symptoms is given

• Rules specify how many symptoms must be present for a diagnosis to be given

• Who comes up with the number of symptoms? Additionally, despite adding specifiers, exclusion criteria, and fail-safes, humans do not follow rules

DSM and money (3)

• DSM has been accused of generating new editions for profit. They estimated to have generated $80 million USD on the DSM-V.

• 69% of the DSM-5 task force reported having ties to pharmaceutical companies

• Panel members who received renumeration from drug companies worked in diagnostic areas where drugs were standard treatment

What does the vanishing consensus effect show?

A variation between 19 and 163 SD diagnoses depending merely on the manual being used means the criteria is not reliable and possibly not valid

Although DSM is American, and ICD-11 is European, what do they have in common?

They reflect western models of psychopathology that distinguish between mind and body

Although presented as invariant, incident rates are what?

Highly culturally variant

What is a key example of cultural variance in incident rates? (3)

Studies on British Afro-Caribbeans

Found that they are between 2 and 18 times more likely to be diagnosed with Paranoid SD or mania, with most studies appearing to fall around 8x

Hypotheses such as cultural insensitivity (in diagnosis), genetics, and poverty were all ruled out

What was the cause of higher rates of SD in British Afro-Caribbeans?

Racism. Boydell et al found rates of SD were highest in Afro-caribbeans who lived in parts of the city that formed a smaller proportion of the population. Yet, the DSM would say we all have the same chance of getting it.

What are a few diagnostic trends in the UK? (5)

• Steep rise in diagnoses (espec anxiety, depression, ADHD, autism)

• Long clinic waiting lists, especially for children

• Self-diagnosis on social media

• Increased discussion of mental health

• Steep rise in prescriptions

What are potential causes of the diagnostic trends seen today?

The system is broken

What is epistemic injustice as applied to treatment today?

Unequal power relations deprive people of sound, evidence-based, alternative frameworks to make sense of their own and others’ distressing experiences

Rather than pathologising the person, we should do what?

Look at how their experiences and life factors have contributed to the issues they are facing today

What was the NZ Mental Health Survey?

12992 fully structured diagnostic interviews w/ participants >= 16 yrs

What were results of the NZ Mental Health Survey?

• Prevalence of any disorder last 12 months ~20.7%

• Highest prevalence for disorder groups was anxiety disorders

• Highest prevalence for individual disorders was specific phobia

• Interference with life was higher for mood disorders

Which disorders had the highest proportion of severe cases in the NZ Mental Health Survey?

Drug dependence, bipolar disorder, and dysthmia (over 50%)

What was the proportion of severity in the NZ Mental Health Survey?

Only 31.7% of cases were classified as mild

45.6% moderate

22.7% serious

How do results of the NZ Mental Health Survey compare to other World Mental Health surveys?

Relatively high (but always a little lower than the US)

What has led to less than a third of cases in the NZ Mental Health Survey being considered mild?

For all disorders (except specific phobia), interference w/ life was reported to be moderate on average. Most people who have ever met full DSM-IV criterion find their disorders impact on their lives to a non-trivial extent

How does ethnicity relate to results of the NZ Mental Health Survey?

12 mth prevalence of any disorder highest in Maori (29.5%), followed by Pacifika (24.4%) and others (19.3).

Adjustment for age, sex, education and household income reduced differences to 23.9, 19.2, 20.3, respectively

What is the compounding effect of mental distress for Maori?

Higher rates of mental distress and disorders combined with understandable reluctance to engage with Western-based services