I recently learned of an exciting new blog on the history of psychiatry which was launched earlier this year. H-Madness
is a collective blog edited and written by a team of historians with what looks to be an impressive roster of guest contributors. The historians behind the site are Greg Eghigian
(Penn State University), Eric J. Engstrom
(Humboldt Universität), Andreas Killen
(City College of New York), and Benoît Majerus
(Université libre de Bruxelles) and as they write in the blog’s description:
H-Madness is intended as a resource for scholars interested in the history of madness, mental illness and their treatment (including the history of psychiatry, psychotherapy, and clinical psychology and social work). The chief goal is to provide a forum for researchers in the humanities and social sciences to exchange ideas and information about the historical study of mental health and mental illness. The blog, therefore, primarily serves university and college faculty, students, and independent researchers.
Initial posts have included a link to an interview with Jonathan Metzl
(speaking about his new book The Protest Psychosis: How Schizophrenia Became a Black Disease
), numerous conference announcements, calls for papers, journal article abstracts, and links to articles on psychiatry in the popular media.There will also apparently be series of invited guest posts. The first of these series–which is being posted this week–concerns the proposed changes
to the American Psychiatric Association’s Diagnostic and Statistical Manual
(DSM), which were made public in February. The series was kicked off with a post
by Allan Horwitz
(author, along with Jerome Wakefield
, of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder
) arguing that a number of proposed changes to the next edition of the DSM “could lead to an enormous pathologization of non-disordered conditions,” (Horwitz 2010
). Two of the three proposed changes Horwitz focuses on strike me as relatively straightforward, in that I can see how these might facilitate the pathologization of persons or conditions which would otherwise not be viewed through the lens of mental disorder: 1) the removal of the bereavement exclusion from the criteria for the diagnosis of Major Depressive Disorder; and 2) the creation of “at-risk” categories for some mental illnesses–particularly psychotic conditions.
The third proposed change which Horwitz discusses is particularly interesting because it has been widely described as a step in a positive direction by anthropologists and cultural psychiatrists who work on mental distress or psychopathology: that is, the adoption of dimensional assessments for diagnoses which are currently categorical. As Emily Ng wrote in her recent report on the FPR-UCLA conference on the Cultural and Biological Contexts of Psychiatric Disorder,
a number of conference participants argued that a dimensional approach to diagnosis could provide a more accurate and nuanced way of assessing the conditions of particular patients at a particular point in time. While Horwitz also sees the potential value of such approaches, he argues that the propsed version “has the promise of massively medicalizing natural emotions,” (Horwitz 2010
On the surface, this proposal sounds sensible and desirable. Major Depression, for example, requires the presence of five symptoms but there is no natural cut-off point between four and five symptoms, or at any other particular point for this diagnosis. Depression, as well as the other major conditions in the DSM, seems to naturally be a continuous rather than a categorical condition.
The problem in dimensionalizing common conditions such as depression and anxiety is that a small number of “subthreshold” symptoms typically indicate a non-disordered condition, not a milder form of disorder. The only way to accurately use a dimensional system is to initially use criteria for disorder that separates natural from disordered conditions, regardless of how many symptoms are present. If adequate conceptions of disorder first distinguish contextually appropriate symptoms that are commonly transitory responses to stressors from mental disorders, then dimensional measurement could represent a distinct improvement in the DSM
. As the discussion of bereavement indicates, however, the separation of disorders from non-disorders in the DSM-V
seems to be getting worse rather than better. The current proposal to dimensionalize measures of frequently occurring disorders threatens to pathologize even mildly distressing conditions. While potentially valuable, it needs reconsideration and reformulation. (Horwitz 2010
There will apparently be more posts on the proposed DSM revisions throughout the week, so check back if you’re interested. All around H-Madness
looks like an excellent addition to the psy-blogosphere.
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