Snake Phobias, Moodiness and a Battle in Psychiatry

June 14, 2005
Snake Phobias, Moodiness and a Battle in Psychiatry
By BENEDICT CAREY
(recommended by Dennis Raphael)

A college student becomes so compulsive about cleaning his dorm room that his grades begin to slip. An executive living in New York has a mortal fear of snakes but lives in Manhattan and rarely goes outside the city where he might encounter one. A computer technician, deeply anxious around strangers, avoids social and company gatherings and is passed over for promotion.

Are these people mentally ill?

In a report released last week, researchers estimated that more than half of Americans would develop mental disorders in their lives, raising questions about where mental health ends and illness begins.

In fact, psychiatrists have no good answer, and the boundary between mental illness and normal mental struggle has become a battle line dividing the profession into two viscerally opposed camps.

On one side are doctors who say that the definition of mental illness should be broad enough to include mild conditions, which can make people miserable and often lead to more severe problems later.

On the other are experts who say that the current definitions should be tightened to ensure that limited resources go to those who need them the most and to preserve the profession's credibility with a public that often scoffs at claims that large numbers of Americans have mental disorders.

The question is not just philosophical: where psychiatrists draw the line may determine not only the willingness of insurers to pay for services, but the future of research on moderate and mild mental disorders. Directly and indirectly, it will also shape the decisions of millions of people who agonize over whether they or their loved ones are in need of help, merely eccentric or dealing with ordinary life struggles.

"This argument is heating up right now," said Dr. Darrel Regier, director of research at the American Psychiatric Association, "because we're in the process of revising the diagnostic manual," the catalog of mental disorders on which research, treatment and the profession itself are based.

The next edition of the manual is expected to appear in 2010 or 2011, "and there's going continued debate in the scientific community about what the cut-points of clinical disease are," Dr. Regier said.

Psychiatrists have been searching for more than a century for some biological marker for mental disease, to little avail. Although there is promising work in genetics and brain imaging, researchers are not likely to have anything resembling a blood test for a mental illness soon, leaving them with what they have always had: observations of behavior, and patients' answers to questions about how they feel and how severe their condition is.

Severity is at the core of the debate. Are slumps in mood bad enough to make someone miss work? Does anxiety over social situations disrupt friendships and play havoc with romantic relationships?

Insurers have long incorporated severity measures in decisions about what to cover. Dr. Alex Rodriguez, chief medical officer for behavioral health at Magellan Health Services, the country's largest managed mental health insurer, said that Magellan used several standardized tests to rate how much a problem is interfering with someone's life. The company is developing its own scale to track how well people function. "This is a tool that would allow the therapist to monitor a patient's progress from session to session," he said.

Although the current edition of the American Psychiatric Association's catalog of mental disorders includes severity as a part of diagnosis, some experts say these measures are not tough or specific enough.

Dr. Stuart Kirk, a professor of social welfare at the University of California, Los Angeles, who has been critical of the manual, gives examples of what could, under the current diagnostic guidelines, qualify as a substance abuse disorder: a college student who every month or so drinks too much beer on Sunday night and misses his chemistry class at 8 a.m. Monday, lowering his grade; or a middle-aged professional who smokes a joint now and then drives to a restaurant, risking arrest.

"Although perhaps representing bad judgment," Dr. Kirk wrote in an e-mail message, these cases "would not be seen by most people as valid examples of mental illness, and they shouldn't be because they represent no underlying, internal, pathological mental state."

Separating the heavies from the lightweights - by asking, say, "Did you ever go to a doctor for your problem, or talk to anyone about it?" - has a significant effect on who counts as mentally impaired.

After researchers reported in a large national survey in 1994 that 30 percent of Americans adults had a mental illness in the past year, Dr. Regier and others reanalyzed the data, taking into account whether people had reported their mental troubles to a therapist or friend, had received treatment or had taken other actions.

They found that the number of people who qualified for a diagnosis of mental illness in the previous year plunged to 20 percent over all; rates of some disorders dropped by a third to half.

But limiting the count to those who have taken action does not give an accurate picture of the extent of illness, argue other researchers, who have been sharply critical of efforts to drive down prevalence estimates.

Dr. Robert Spitzer, a professor of psychiatry at Columbia University and the principal architect of the third edition of the diagnostic manual, wrote in a letter to The Archives of Psychiatry, "Many physical disorders are often transient and mild and may not require treatment (e.g. acute viral infections or low back syndrome). It would be absurd to recognize such conditions only when treatment was indicated."

He added, "Let us not revise diagnostic criteria that help us make clinically valid standard diagnoses in order to make community prevalence data easier to justify to a skeptical public."

Dr. Ronald Kessler, a professor of health care policy at Harvard and the lead author of the 1994 survey and the nationwide survey released last week, said squeezing diagnoses so that many mild cases drop out could blind the profession to a group of people it should be paying more attention to, not less.

"We know that there are prodromes, states that put people at higher risk, like hypertension for heart disease, which doctors treat," he said. "You can call these milder mental conditions what you want, and you may decide to treat them or not, but if you don't identify them they fall off the radar, and you don't know much of anything about them."

In the survey released last week, Dr. Kessler and his colleagues found that half of disorders started by age 14, and three-quarters by age 24. "These are people who may show up at age 25 or later as depressed alcoholics, maybe they're in trouble with the law, they've lost relationships, and from my perspective we need to go upstream and find out what's happening before they become so desperate," Dr. Kessler said.

One condition whose estimated prevalence has bounced around like a Ping-Pong ball in this debate is social phobia, extreme anxiety over social situations. In a 1984 survey, investigators identified social phobia primarily by asking about excessive fear of speaking in public. They found a one-year prevalence rate of 1.7 percent.

But psychiatrists soon concluded that other kinds of fears, including a fear of eating in public or using public restrooms, were variations of social phobia. When, in 1994, these and others questions were included, the prevalence rate rose to 7.4 percent.

Dr. Regier re-evaluated the data using a different criterion for severity and found a much lower rate: 3.2 percent. Last week, Dr. Kessler reported a rate of 6.8 percent.

"You can see why people have a hard time believing these numbers because they change so much depending on how you look at the data," said Dr. David Mechanic, director of the Institute for Health, Health Care Policy and Aging Research at Rutgers University.

Yet the cutoff points for disease severity have real effects on the lives of people like Paul Pusateri, 48, a Baltimore business analyst.

Mr. Pusateri said he was outgoing through college but then had a panic attack in his mid-20's, as he was preparing to give a speech. He managed to build a career and family despite surges of anxiety before speeches and meetings. But finally, more than two decades after the first symptoms, he reached a point where he dreaded even small or one-on-one meetings with familiar co-workers.

"It's very bizarre; the only way I can describe the feeling is, Imagine walking down the street at dusk having someone put a gun in your face and threaten to kill you - having that absolute terror before a routine work meeting," he said.

Mr. Pusateri said that, perhaps unconsciously, he applied severity criteria to his own growing mental struggles. He may have set the bar too high: only when he began badly mangling presentations at work, and then dreaded going in at all, did he tell his wife that he felt he was in trouble. His wife had watched a therapist talk about social phobia on television, and soon he was getting help.

He considers himself lucky to have found a diagnosis at all, not to mention a therapist. "I was desperate by the time I did anything about it, I saw that my livelihood was at stake," he said.

Yet by all outside appearances, and by some strict definitions, he might not have qualified as having a disorder until he took some action.

In the coming years, Dr. Regier's office will be responsible for clarifying the thresholds of disease for the next diagnostic manual, to somehow identify difficult cases like this one, while remaining credible to insurers and to the public at large.

After a prolonged controversy last year over the use of antidepressants in children, most experts say the last thing psychiatry needs now is for this process to turn into a public fight over who is sick and who is not.

But this fight may be hard to avoid. The two sides are far apart, debates over the diagnostic manual are traditionally contentious and despite increasing openness about mental illness the public tends to be skeptical of any prevalence numbers over a few percent.

"That's the problem," said Dr. Regier, "people hear these higher prevalence rates and they immediately start thinking about severe, disabling schizophrenia. But we know these surveys include a lot of mild cases, and we need to ask, How significant are these?"

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