There will never be a lab test for some mental health disorders

Because they aren’t really “disorders” when you consider the “symptoms” in context.                                                                                                                                                                                                                                                                                                            


One of the first things any new student in family therapy learns about is the genius of the acting-out child. Children are keen observers of the world around them: If they learn that one kind of scream or cry or tantrum gets their parents’ attention where another kind does not, they are quick to do what works and give up on what doesn’t.

Children are also, for obvious reasons, incredibly observant of their parents’ relationship (whether to each other, or in blended or single-parent families, to the new partner). For kids, seeing their parents fighting can be utterly terrifying.

Some kids, in the midst of a parental argument, learn to stay out of the way. Other kids learn, even by accident, that a very good way to get the parents to stop arguing with each other is to break rules, scream, or otherwise behave inappropriately. Here is where acting out is so smart: if both parents get angry at the kid for misbehaving, at least they stop arguing with each other for a while.

For a child, the pain of having your parents angry at you may be far preferable to the terror experienced when watching them fight each other.

Of course, parents are often reluctant to see this. They may instead perceive such a child as “hard to handle,” “defiant,” or otherwise broken. In the worst cases, health care professionals buy into the parents’ descriptions, slapping diagnostic labels on the child. Labels like “attention-deficit hyperactivity disorder” or “oppositional defiant disorder” may accurately describe a child’s behavior, but they ignore the cause, and tend to focus attention on the child as the problem.

A skillful family therapist will assess not just the child but also the child’s entire social environment, including their family, to see whether the acting-out behavior is actually smart. If it is, then therapy focuses not on “curing” the acting out, but instead on making it no longer necessary. The family therapy field is rife with stories of children diagnosed with attention-deficit disorder, childhood bipolar disorder, or other mental illnesses who are rapidly “cured” once their parents start coming in to therapy sessions — especially if the parents are willing to work on their relationship with each other.)

Of course, we don’t stop being impacted by our social worlds when we become adults. Just as the acting-out child is often behaving in a way that is quite smart given their environment, adults who appear to have mental illnesses may be responding intelligently to the world around them. This may mean their behavior is a response to the work environment, social circle, family, or even larger society. For example, William Glasser suggests that at least some of the higher prevalence of depression among women might actually be a wise response to the impossibly high demands placed on women to be successful at work, at home, and socially, always with a smile on. For women who experience that pressure intensely, and do not feel they have a reasonable way of escaping or easing it, depression can be a quite reasonable way of checking out of that chase without having to actively fight social norms. (For clarity, Glasser is not suggesting blaming the depressed for their depression; he does argue that depressive behaviors are sometimes chosen, but goes on to say these choices are often not conscious. Depression may be an adaptive response to difficult circumstances, Glasser says, but it certainly is not ideal.)

Ultimately, whether we are talking about children, adolescents, or adults, it is often true that behavior that might look troubling or even “ill” in one context is actually quite helpful in another. In fact, sometimes taking on behaviors that appear crazy to others is actually the smartest thing to do. It’s evidence of good health and adaptability, not an underlying problem with the brain or body that any lab test could detect.

That’s why, for as much as I support the National Institutes of Mental Health’s effort to usher in a new era of hard science in mental health diagnosis (and usher out the behavior-based diagnoses of the DSM-5), I wonder who it will leave out in the cold. The simple fact is that many people who now (appropriately!) receive diagnoses and are eligible for insurance-covered treatment for mental disorders are not, in any physiologically-testable way, disordered. They are actually quite healthy. Their behavior makes perfect sense when understood in context.

# # #

Your comments are welcomed. You can post them in the comments below, by email to ben[at]bencaldwell[dot]com, or on my Twitter feed.

National Institutes of Mental Health abandons DSM-5

Just weeks before the new diagnostic manual is released, NIMH cites “lack of validity” and says “patients with mental disorders deserve better.”

PET-imageIn a surprising announcement just weeks before the scheduled release of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the US government’s mental health research arm has announced plans to stop using DSM categories in its work.

The National Institutes of Mental Health (NIMH) is the single largest funder of mental health research in the world. In his announcement last week explaining the decision, NIMH Director Thomas Insel wrote that “Symptoms alone rarely indicate the best choice of treatment.” While diagnositic categories based on clusters of symptoms — like the categories in the DSM — provide a common language that mental health care providers and researchers can use, these categories are more about that consistency in usage (i.e., reliability) than they are about clinical or research validity. Such symptom-based diagnosis, Insel argued, is now outdated in most other areas of medicine.

So NIMH is scrapping DSM categories when funding future research and is developing its own framework to “transform diagnosis by incorporating genetics, imaging [such as the PET scan pictured above], cognitive science, and other levels of information to lay the foundation for a new classification system,” according to Insel. For now, the new classification system is just a framework for research. But the clear intention is to make the DSM obsolete.

As a family therapist, I find the DSM-5 categories to be both useful and limited in the ways Insel described. They are a good tool for communicating with other professionals, but not especially useful for clients, beyond establishing that others may have similar suffering. I like the idea of a new classification system for mental disorders based on biology and verifiable laboratory tests (indeed, I think it’s overdue), and think it quite likely that such a system will strongly support systemic and relational therapies. The brain is a social organ, after all, and therapy creates verifiable physiological changes in the brain.

# # #

Your comments are welcomed. You can post them in the comments below, by email to ben[at]bencaldwell[dot]com, or on my Twitter feed.