Beyond ADHD: Moving Past the DSM Paradigm of Mental Illness

Claudia Gold, MD
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A paradigm is a way of thinking about things. For the past 60 or so years, our thinking about mental health and illness has been dominated by what can be referred to as the “DSM (Diagnostic and Statistical Manual of Mental Disorders) paradigm.” What this looks like in everyday practice is that when a child is referred to my behavioral pediatrics practice for anxiety, the questions that parents, referring doctors, and teachers ask is, “Does he have anxiety disorder?” followed by “How to we manage his behavior?” and “Does he need medication?”

The DSM paradigm has been useful as a way of organizing our thinking. But it is important to recognize that these “disorders” of anxiety, depression, ADHD are simply lists of symptoms that tend to go together. They do not correspond to any known biological processes in the way that, for example, diabetes is a result of lack of insulin.

When the DSM system was first created, we did not have the powerful health insurance and pharmaceutical industries that we have today. Because of the existence of these entities, we are currently in a position of being forced into a very narrow view of mental health and illness.

The DSM system is a black-and-white paradigm, with only the possibility of “normal” or “disordered.” According to the DSM paradigm, if the answer to the first question about my anxious patient is “no,” and there is no diagnosis, then there is no insurance coverage, and no help. But clearly such a family is struggling.

We need a paradigm shift: a fundamental change in approach and underlying assumptions. A new paradigm is needed that gives room for the complexity that we have learned from the abundance of research at the interface of developmental psychology, neuroscience and epigenetics.

The child noted above may have a strong family history of anxiety traits. He may have a strong genetic vulnerability for anxiety. However, if a parent who shares these traits was slapped across the face for her “difficult behavior” when she was a child, she may become so overwhelmed with stress in the face of her child’s challenges that she is unable to help him to manage his anxiety. Marital conflict, perhaps exacerbated by the stress of a child who is struggling, can further add to the complexity. The environment in which this child grows and develops will determine the way in which his genetic vulnerability is expressed.

As I described in a previous post, the growing discipline of Infant Mental Health offers just such a paradigm. This discipline is characterized by four key components. First and foremost, it is relational, recognizing that humans (and that includes their genes and brains) develop in the context of caregiving relationships. Second, it is multidisciplinary. Experts in infant mental health offer different perspectives.  They come from many fields, including, among many others, developmental psychology, pediatrics, nursing, and occupational therapy.  Third, it encompasses research, clinical work and public policy.  The field looks at mental health within the context of culture and society. And last, it is reflective, looking at the meaning of behavior, not simply the behavior itself. The ability to attribute motivations and intentions to behavior is uniquely human, and research has shown that this capacity is closely linked with mental health.

This paradigm gives us a way to organize our thinking about the problems of the family I describe above.  It offers a path to treatment, namely to support the efforts of the child’s parents to recognize the complex meaning of his behavior. Once parents feel heard and understood, and have the opportunity to make sense of their child’s behavior, they will be better able to help him manage his anxiety. They might involve him in physical activities or creative activities that help him to feel calm in his body. They might get help for their own relationship. They might work together with the child’s teachers to strategize about how to support him in the school setting.

A number of years ago, thanks to my first book, Keeping Your Child in Mind, I had the honor of being invited to give the Paul A. Dewald lecture at the St Louis Psychoanalytic Institute.  My book is about the idea that rather than jump to “what to do” about a child’s behavior, it is important to simply “be” with that child; to think about that child. As I prepared the talk I came to recognize that the same holds true for our whole system of mental health care.  Before we can plan “what to do” to apply the wealth of research I refer to above, we must first recognize that we need to “think” differently. We need to embrace a paradigm shift.  An important first step is to name it as such.

6 COMMENTS

  1. Great piece! Kids can’t be kids nowadays. My 8 year old cousin in law was just put on stimulants for a time because of what his mother calls “behavioral problems”…. She says these things right in front of him, too. And then after they leave everyone’s like “did you see how he *acted*?” No… No I didn’t. I saw a wierd mother who just got divorced and remarried, give the poor fucking child a break!! When I was his age (’95), my mom made me open wide and lift my tongue to make sure I took my antidepressants. What is with these people? Thanks for letting me ventilate myself. Bye.

  2. Oh…looks like I’m first. While I’ll leave the crux of this discussion to those for whom it is primarily intended,

    For the past 60 or so years, our thinking about mental health and illness has been dominated by what can be referred to as the “DSM (Diagnostic and Statistical Manual of Mental Disorders) paradigm.”

    More basically, “thinking about ‘mental health and illness” has been dominated by the notion that we are dealing with matters of health and illness, and that when psychiatry is involved metaphors may be taken literally. Most of the ensuing issues, including DSM, are results of that initial misconception.

  3. I’m going to debate a few of this article’s statements, some of which in my view reflect a type of thinking that can be called “Medical Model Lite”:

    “For the past 60 or so years, our thinking about mental health and illness has been dominated by what can be referred to as the “DSM (Diagnostic and Statistical Manual of Mental Disorders) paradigm.”

    Slight quibble here – I’d say it’s the last 35 or so years, since the DSM III came out in 1980. The earlier DSMs featured many more conditions that were not explicitly labeled as medical illnesses of the brain. The earlier DSMs were also not so important for insurance purposes nor so heavily a part of public discourse.

    “The DSM paradigm has been useful as a way of organizing our thinking.”

    I would argue that this is an illusion. The DSM might make treatment providers think they know what they are seeing. But as Sami Timimi has discussed in his talks available on YouTube, there have no studies showing that researching around a particular diagnosis improves outcomes for that supposed condition. What studies we do have suggest that targeting treatment at particular diagnoses does nothing to improve outcomes. So how is the DSM paradigm really useful? The DSM has been useful primarily as a means to legitimize psychiatry as a medical discipline, to increase drug sales, to increase psychiatrist incomes, and to increase insurance reimbursement.

    “But it is important to recognize that these “disorders” of anxiety, depression, ADHD are simply lists of symptoms that tend to go together.

    I also dispute this opinion, offered as if it were a fact but without evidence – the British Psychological Association has shown that the symptoms which supposedly “go together” in labels like schizophrenia or bipolar or depression, actually do not cluster together in the way that would be expected if the diagnoses referred to a phenomenon really existing in the external world. Paris Williams wrote about this in his excellent book, Rethinking Madness.

    “He may have a strong genetic vulnerability for anxiety.”

    In my opinion Claudia Gold needs to do some self-education on how genes and the environment interact. I recommend the book, “The Mirage of a Space Between Nature and Nurture” by Evelyn Fox Keller. It’s the complex dynamic interaction between genes and the environment (which modifies genes after birth) over a lifespan that lead to one’s vulnerability to whatever stresses are occurring in the present… Genes are in fact being modified by the environment’s influence on them after birth (epigenetics), something that appears to be ruled out by this statement. So vulnerability to “anxiety”, whatever that means, is not static or set from birth. Another good author on this is Matt Ridley, the Dependent Gene.

    “The environment in which this child grows and develops will determine the way in which his genetic vulnerability is expressed.”

    To repeat the last paragraph… Again to me this is showing a misunderstanding of genetic vulnerability as being a static set thing that exists and endures from birth. Rather, environment actively changes genes and actively modifies the genetic level of vulnerability after birth. Things are much more complex and malleable than this somewhat essentialist statement suggests. To me this is where the medical model starts to creep into the author’s thinking, perhaps unconsciously.

    Now as to what I agree with – which is a majority of this article. Absolutely we need a paradigm shift, long overdue. Mental health problems should be conceived as existing along a continuum with psychic health and wellbeing, with no exact cut-off point where one can say this person is sick or that person is normal. Mental health problems should be first linked to social issues and psychological understandings, and last focused on biology/physical causes. Biopsychosocial should be renamed SOCIALPSYCHObio, with a little bio.

    The author’s Infant Mental Health approach sounds good to me.

  4. There are a lot of paradigms for how we perceive human behaviors, thoughts, feelings, and interactions that are not of any medical or pyschological paradigm or organizing principles. For example, spiriutal healing is about the path of unity consciousness, integration of yin/yang–i.e., masculine and feminine–for the purpose of healing social and pyschic splitting.

    From this perspective, what creates the illusion of ‘mental illness’ comes from existing in a highly competetive, materially-oriented, power-based dulaistic society, considered spiriually bankrupt, because this split in society is what generates the stigma which leads to marginalization–a core cause of exterme distress, rage, hopelessness, distortions of self, etc.

    The spiritual tranlsation for ‘mental illness,’ therefore, would be ‘spiritual dissociation,’ in that a person is not aware of their own spirit (above and beyond their physical body), and so they are missing out on their internal guidance and self-healing aspects of self. That’s quite a bit of darkness within the psyche, and is what makes us dependence on others–for just about everything.

    In spiritual healing, the intention and work is to connect with these aspects of self, so that people can know their own nature, trust their own process, and take care of themselves as they wish, independent of any school of thought, because it is their self-wisdom guiding them. This is the essence of awakening.

    I like this paradigm it translates into the power of trust, self-care, and ownership as, both, the tools and goals of healing and self-empowerment, and I believe it is also the path to personal freedom on all levels.

    • Oh yeah, the other aspect of spiritual dissocation is that it leaves us only in communication with our ego, which is a fear-based perspective and reality (fear of losing, fear of failing, fear of erring, fear of coming across as less then, etc). Chronic fear leads to chronic distress from dread, panic, and paranoia.

      Stigma is fear-based an divisive, whereas mutual respect occurs when we have a sense of love about ourselves. Spiritual connection happens through the heart, which is a loving feeling, so via this connection, we are guided through love, as opposed to being guided by fear, which only leads to more darkness, that’s a rabbit hole, neverending.

      I think this perspective of spirituality aligns with mental illness and mental distress down the line: fear-based reality vs love based reality. The difference, I think, is indicated by our level of integrity and mutual respect–kindness vs. meanness.