MW: When cancer research started, it was first to try to find commonalities among the many illnesses people with cancer had. The first treatment efforts improved conditions only a very little, but it was by using each effort and tweaking treatment again and again that the field moved forward to where it is today.
AH: I also heard (from Dr. Carl C. Bell of the University of Illinois at Chicago) about a study that showed that stigma was actually increased after the community was educated that psychiatric illnesses are biological illnesses. Before the educational intervention, people with mental illness were seen in the community as odd or quirky and accepted as "different." After the study, these same people were shunned by the community as having an immutable biological disease.
MW: What about child mistreatment? Don’t you think that would be good to include in the DSM? What about domestic violence? And there is a big push to include parental alienation syndrome. What do you think about that?
AH: I don’t see these as psychiatric illnesses, [they are] more social or criminal problems. I don’t think couples with IPV [interpersonal violence] would come for treatment if they knew that they would be labeled by the insurance companies or doctors. I think the parental alienation syndrome is also not a good thing to put in the DSM, whatever the science (or not) behind it. It is a social problem that parents do bad things to their children. I do not see that as a psychiatric issue.
MW: But we treat these people. They come to us for help, and we try to help them. I think it is better to have clear definition that is well thought out and scientifically based, rather than just vague and impressionistic. Relational problems have been written about for years. There is a huge literature on this topic. I think that the evidence for many relational processes that lead to morbidity is at least as good, if not better, than many diagnoses in the DSM-IV.
AH: I agree. However, my conclusion is that we should take things OUT of the DSM that don’t belong there and prevent social or criminal diagnoses from going into the DSM.
MW: How are we going to measure and be scientific about our work?
AH: I think we can do that without using the DSM. Why is the DSM so important? I also don’t think we should let insurance companies dictate how we think about what we do.
MW: Insurance companies pay for treating persons with some diagnoses, but not other diagnoses. For example, in some states, they do not pay for treatment for ADHD, which is extensively researched to be a primarily heritable illness, responsive to medications more than even very intensive psychotherapeutic interventions, and quite disabling for some youth. The DSM has to be used for more than merely what insurance companies decide what to do with it. It originally began as a method of reliably describing patients that psychiatrists were treating, so as to share knowledge about the illnesses, what worked, and what did not work. The [people behind the] ICD-9, 10, and now 11, also think that relational disorders are important to include. We don’t want to be a country left behind!
AH: A good question is, "What is the DSM for?"
MW: To provide a framework for us to diagnose and treat mental illness.
AH: Should it not just focus on biological disease? That is my preference of a system that calls itself a disease manual.
MW: But that is not what the DSM is. It reflects the biopsychosocial model and includes behaviors and clusters of symptoms that are a focus of treatment.
AH: I am not a biological psychiatrist; (I’m) more of a social and family psychiatrist, but I see the DSM as being a biological manual. I think it is hard to categorize social and family behaviors that can be pathological in one situation or culture and not in another. Take expressed emotion (EE). Research in Japan has found that two components of high EE – high criticism and high overinvolvement – need to be parsed out and that families benefit from specific treatments, depending on which component of high EE is present. I don’t think that relational diagnoses are fixed enough. This is another argument.