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Thursday, March 07, 2013

When Does Fear Become a Disorder?

APA In his review of All We Have to Fear: Psychiatry's Transformation of Natural Anxieties Into Mental Disorders, Jonathan Abramowitz describes sensations and experiences that most of us can identify with. What parent has not experienced a sense of almost terror at the sight of a child's dash toward the street; a curfew violation; or a child's failure to respond to telephone calls, text messages, or an e-mail in what a parent considers a reasonable or expected time frame? Who cannot recall the rapid breathing and sweaty palms that accompany the emotions before a big speech or performance, first date, or first day on a new job?

As Abramowitz notes, most of us get through these events without therapy or medication, and may actually congratulate ourselves for the ability to do so and ultimately respond positively. Abramowitz states, "Horwitz and Wakefield's overarching contention is that the DSM's symptom-based diagnostic system needlessly pathologizes normal everyday anxieties." However, in our personal and professional lives we encounter many people who find it difficult to cope with these expected, seemingly ordinary challenges of life. The challenge for mental health professionals is to determine when these individuals require intervention. Do we know exactly when to offer psychotherapy, offer a medication referral, or reconceptualize the anxiety? Does psychology, as a profession, have a responsibility to educate the public about its potential to pathologize normal responses? Are these research, clinical, or ethical questions?

Read the Review
ReviewDSM, Organized Psychiatry, and the Pharmaceutical Industry: That’s What We Have to Fear
      By Jonathan Abramowitz
      PsycCRITIQUES, 2013 Vol 58(7)


Dr. Judith Schlesinger

It's more critical than ever for psychologists to uphold the distinction between true pathology and what was once quaintly called "problems in living."

As the DSM-5 slouches toward Washington to be born, the challenge of defending the integrity of "normal" has never been greater. But the question is: who will do it?

Not those colleagues who have surrendered to the medical model in an attempt to make a decent living - all the psychologists, social workers, and others who have quietly bought the LPN credential so they can prescribe medication for every blip, slip, bump and gasp of daily life.

Not those parents and educators who want real physiological "diseases" that get them off the hook and qualify their problem children for extra services.

And, most certainly, not those responsible for the exponential increase in disorders that can be "fixed" with pills, since they are also those who accrue the most benefit from them. Psychiatry and Big Pharm can thereby afford the massive advertising campaigns and academics-for-hire to assure the gullible and blame-phobic public that everything is safe, effective, and right as rain.

So, what's next?

Monica Fung

The medical system is different in Hong Kong and there is no insurance coverage even with the label in DSM5. Psychiatric public resources are limited and private service is expensive. Hence, the problem of expanding diagnosis in DSM5 and pathologizing “normal behavior” probably is not as serious as in America.
In addition, on the point of educating general public about “normal” emotional responses, it seems strange in our society. It is unimaginable ,in Chinese culture, to have psychologists to tell us whether we are “normal” when feeling anxious on a coming examination; feeling angry with a rebellious teenage son or feeling unhappy on losing an employment. Is it a natural endowment in human being that, from day to day, we experience good and bad and survive the good emotion and negative emotion. On experiencing life events, either ourselves, or our friends and families, can tell if we need help or not. I agree that educating general public on mental health is important all the time. However, will educating people on what is “normal” weaken the self-regulatory ability in people and create reliance on “experts”?

Adrian Mark

Certainly, normal anxiety disorder gets pathologized and categorized into a kind of mental disorder that seems logic in a commercial world. Nowadays, we see often health care service becomes part of the packaged product/ service.

We cannot just blame on any psychiatrist/ psychologist. The system itself is in flaws. When a patient is covered by health insurance, it is normal to get diagnosed and found mentally ill so as to support the reimbursement of insurance procedures.

While cognitive-behavioral approaches can regulate many mental issues, why would psychiatric drug have to take an import role in the cure of mental disorder? It is simple a game of big pharmaceutical firms wanting to increase their endless sales quote at costs of patients. These companies discovered long time ago, mentally illness represents a sector of tremendous business possessing lots of money-making potentials. By promoting prescriptions of drug, they can easily tap into this market.

When compared to Hong Kong, what happened in the U.S. seems an interesting development of mental health service. The situation here is very different. Hong Kong people acquire both Chinese traditional and legacy British colonial culture. What we seem from the outside, we are relatively westernized comparing to many of Mainland Chinese people. It may be not wrong claim, but still we are quite conservative in many aspects.

First mental health survey for Hong Kong by BBC news pointed out when someone was discovered he was with bipolar disorder. His colleagues would reject taking the elevator with that person. We can see how poor misconception of mental illness can be in the city. According to this report, Hong Kong only 0.25% of the GDP on mental health. When patients want to get mental health service in public establishments, it can take about 2 years to get the first visit.

Under this atmosphere, we see how government and the general public perceive mental health. The birth rate has dropped dramatically in the last decade, most families either choose not to have infants or only selectively have one. Thus, there are much more effort in bringing up children more than ever before. When it comes to education and many families may spend a consideration time, effort and money in their next generation. The same level of treatment also is found among elderly citizens. Hong Kong inhabitants are rapidly aging, our average ages are claiming higher. We are second position after Japan in this realm in Asia. The more dedicated care service increasingly has been made available to old people including mental health. That is why there are voices urging the government to review the situation and improve the policy of mental health care.

This coming years will be important to examine whether we should depend on either public service or private consultation or both in parallel. Perhaps not yet today, but we would expect to experience the same problem of overly promoted psychiatric drug saturating in this territory in years to come.

Catherine Walker, First mental health survey for Hong Kong
BBC news (2011) Hong Kong conducts first mental health survey

Jonathan Wong

I think all mental health care professionals have a common responsibility to educate the general public about the fundamental differences between health versus disease. Some may ask why bother talking about normal responses as it is such a commonsense topic. Such effort is essential because we are living in an era of medicalization of normality and we are losing the awareness about our self-healing capacities.

A prominent psychiatrist, Allen Frances who was the chairman of the DSM-IV Task Force, expressed these views in a clear and strong manner in his recent publication: “Saving Normal: An insider's revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life.” He warned about the risks that DSM-5 would mislabel normal people, promote diagnostic inflation, and encourage inappropriate medication use. He believed that psychiatry is vulnerable to manipulation of the health / disease boundary simply because none of the updated biological findings has ever qualified as a diagnostic test to confirm any mental disorder. The DSM diagnostic criteria have been established through judgment and consensus. Clever marketing from pharmaceutical companies can easily influence these subjective efforts due to the fact that the definition of mental disorder is following, instead of guiding, the practice habits of clinicians who treat, researchers who research, educators who teach and pharmaceutical companies that sell.

Allen Frances, after decades of clinical practice, research efforts and serving as a leader in the DSM-III, DSM-III-R and DSM IV task committees, expressed strong worries about over-diagnosis and over-medicalization. He believed that our mental health could be safeguarded by our brain homeostasis. When people are experiencing negative emotions and mental dysfunctions, if they are given sufficient time, most can resiliently regain balance. Such wonderful outcome can be produced through off-loading excessive stress, rest, and exercise, seeking support from family, friends and the community. When necessary, caring psychotherapists who embrace a non-pathological approach can provide essential help. In this connection, he emphasized that mental disorders should be diagnosed only when the presentation is clear-cut, severe and not going away on its own. Prematurely relying on medication can short-circuit the natural homeostatic healing process.

I strongly echo with his view plus the quote from the wisdom of Hippocrates: “ it is more important to know what sort of person has a disease than to know what sort of disease a person has.”

Frances, A. (2013). Saving Normal: An insider's revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. New York, NY: HarperCollins.

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Editor of PsycCRITIQUES

Danny Wedding, PhD

Chair of Behavioral Sciences,
College of Medicine,
American University of Antigua

Associate Editors of PsycCRITIQUES

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