Wednesday, May 29, 2013

DSM-V and the Wussification of America

A bit of a controversy is arising in psychiatric and psychological circles with the release of the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V).

Many workers' compensation systems rely on earlier editions of the DSM for diagnosis and medical legal reporting of industrial mental health issues in arriving at indemnity equations.

While much of the controversy over DSM-V is the elimination of the Global Assessment of Functioning scale (GAF) which some states, notably California, uses as part of the whole person impairment percentage for determining a permanent disability rating, the more problematic issue with DSM-V is that there are more diagnosable conditions with lower thresholds for meeting diagnostic criteria.

This is part of a wider problem that America faces - the disease-ification of our population; making mountains out of mole hills.

In other words, more people are now being diagnosed with some condition that in the past would not have been an issue.

I'm not sure why this has occurred - perhaps it is our legal system which tries to find ways to pay people for wrongs they have experienced; perhaps it is our insurance system that won't pay for services unless there is some diagnosis; perhaps it is because of our social benefits system (Social Security, etc.) that won't provide benefits unless a physician has made a certain diagnosis.

I don't know - but one thing is for certain, if we are to believe all of these guides and manuals directing the health care community, we are all a lot more sick than we used to be.

Maybe this is a big part of what is driving up medical costs. My psychiatrist brother-in-law quipped once that in medical school they teach that 3/4s of what is wrong with a person is in their heads...

The authors of DSM-V seem to have good intentions.

Dr. William Narrow, the research director of the DSM-V task force and a psychiatrist who works for the Arlington Va.-based American Psychiatric Association (APA), defended the new tome to WorkCompCentral, stating that the new manual moves away from the GAF because it was too easy to game.

Narrow said the APA put the World Health Organization Disability Assessment Schedule Version 2.0 (WHODAS ) in the DSM-V for review and consideration by the mental health community.

Narrow said he felt the WHODAS "does a better job of assessing disability" than the GAF and is "very reliable." The GAF, he explained, "is not a measure of disability" but rather a "measure of overall functioning" that "mixes disability and symptomatology" in a way that the WHODAS does not.

Fair enough, but this unilateral reconstruction of a tool does not take into account myriad and complex systems that already make use of the earlier model.

And while Narrow may be correct about gaming GAF, the fact is that GAF has been in use for many, many years and is a standard without too much objection by those who use it.

Changing standards without legal authority or precedence is not just expensive, it is time consuming and difficult to do because of competing interests and politics.

But, regardless of the elimination of GAF, the fact remains that, as Paul D. Godec of Kissinger & Fellman, a labor and employment attorney in Denver, remarked to WorkCompCentral, "virtually every one of us is going to have some diagnosable condition under the DSM-V."

The broadening of diagnostic criteria just adds to the wussification of America - the removal of personal responsibility in society.

Wussification starts at a young age, with such otherwise benign events as organized sports that recognize every child with an award even if they are a loser.

It continues into adulthood with no-fault systems, such as workers' compensation or divorce, where no one is accountable for their own behavior because they are going to be taken care of regardless of how or who caused an accident or situation.

It seems that nearly everywhere one turns there is no personal responsibility anymore - it's always someone else's fault, or no one's fault. Everyone's a victim...

Whether DSM-V may or may not have an impact directly on workers' compensation systems is irrelevant - DSM-V makes more people ill when they were previously considered to be normally functioning.

We don't need more ill people in this country. We need people that are strong, healthy, vibrant, productive AND WHO TAKE RESPONSIBILITY FOR THEMSELVES. We do this by not recognizing illness when there really isn't any.

Remember the best selling self-help book from the 70's, I'm OK, You're OK, by Thomas A Harris MD? The emphasis of the book is helping people understand how their life position affects their communications (transactions) and relationships.

There are four states according to Harris:
  1. I'm Not OK, You're OK
  2. I'm Not OK, You're Not OK
  3. I'm OK, You're Not OK
  4. I'm OK, You're OK

The most common is number one: As children we see that adults are large, strong and competent and that we are little, weak and often make mistakes, so we conclude I'm Not OK, You're OK.

DSM-V emphasizes that I'm not OK: I'm a wussy and a victim so take care of me...

We need medical manuals that emphasize number four, where people gain the maturity to engage in Adult to Adult dialogue and stop with the victimization mentality that has become so prevalent in American society.

Let's stop the wussification of America and refuse to recognize trite diagnosis that do nothing other than give physicians and other health care providers something new to put on their bills to insurance companies for reimbursement.


  1. As in many things you can probably follow the money and see why this happens. I heard a great story on NPR some time ago which discussed how "osteopenia" became a treatable disease by big pharma which needed to find a way to spread their osteoporosis medication over a larger population of people. Whereas previously osteoporosis was diagnosed with a certain percentage of bone loss, they worked to creat the definition of "osteopenia" for the condition which existed just prior to that percentage of loss being reached. So where previously you either had osteoporosis or you didn't; now you may have osteopenia or osteoporosis, both of which require some sort of treatment. Big Pharma and, I'm sure, others stand to gain from this new diagnosis of problems that were not considered problems before.

    My hunch is that this same process is, at least in part, at play with the DSM. As we know these medical associations who come up with supposedly definitive manuals (e.g. AMAG)are certainly not immune from influence of those who stand to gain the most.