Psychiatry And Modern Science: Perspectives On The DSM

If you have been exposed to modern psychiatry, you have been exposed to the Diagnostic and Statistical Manual of Mental Disorders (DSM) whether or not you are aware of it. This book, often referred to as the "psychiatrist's bible," is the go-to manual for diagnostic criteria of a wide range of mental disorders. Its current incarnation, the DSM-IV-TR (text revision), includes nearly 400 disorders.

Throughout the coming month, we will be delving into some of these disorders in more detail. Before we do that, I think it is important to take a critical look at the DSM, including historical perspectives and future implications.

History of the DSM

The DSM-I was published in 1952 and included 106 mental disorders. It was founded on early principles of psychiatry, namely psychodynamic theory (made popular by Sigmund Freud and Carl Jung). Although an understanding of these historical approaches to psychology are necessary, I find the proportion of textbook pages and lecture time that many modern psychology classes dedicate to this antiquated theory baffling. Early psychodynamics was decidedly unscientific, but many therapists today still cling to its underlying principles. I suppose that old habits die hard, but failure to embrace current trends in mental health science contribute to the stigma that clinical diagnostics, psychotherapy, and psychopharmacology continue to hold in the public eye.

"Scientization" of Psychiatry

Robert Spitzer is arguably the most influential psychiatrist whose name you have never heard. He led the efforts to considerably overhaul the DSM, and in 1980, the DSM-III was published, codified with a strong scientific and medical model. This new version included efforts to statistically quantify incidence rates, demographics, and "calculable" symptomatology. And while the validity of the DSM is still questioned by skeptics, its reliability has come back under fire as well. In the peer-reviewed journal Psychiatry, Ahmed Aboraya writes that "The DSM did improve the reliability of psychiatric diagnoses at the research level. If a researcher or a clinician can afford to spend 2 to 3 hours per patient using the DSM criteria and a structured interview or a rating scale, the reliability would improve. For psychiatrists and clinicians, who live in a world without hours to spare, the reliability of psychiatric diagnoses is still poor." Even Spitzer himself admitted to Alix Spiegel, in a 2005 New Yorker article: "To say that we’ve solved the reliability problem is just not true. It’s been improved. But if you’re in a situation with a general clinician it’s certainly not very good. There’s still a real problem, and it’s not clear how to solve the problem."

Future Diagnostic Efforts

The DSM-V is currently in development. It is slated for release in May 2013. The American Psychiatric Association, the authoring body of the DSM, has partnered with the National Institutes of Mental Health in an effort to present the mental health community at large with the most comprehensive and scientifically accurate diagnostic tool to date. Not surprisingly, this effort has been met with considerable controversy. You can read all about the proposed revisions, including research papers and letters from the task force here.

Bear in mind that this endeavor is significantly limited in terms of transparency. In fact, in early stages of its preparation, the DSM-V task force was required to sign a non-disclosure agreement. This did nothing to calm the fears of those who are skeptical of the relationships and profit-motives possessed by researchers, diagnosticians, therapists, and drug prescribers alike. Spitzer remarked that "When I first heard about this agreement, I just went bonkers. Transparency is necessary if the document is to have credibility, and, in time, you’re going to have people complaining all over the place that they didn’t have the opportunity to challenge anything."

Although the non-disclosure has since been lifted, concerns about full transparency remain. In addition, many individuals are worried about "false positives" in diagnostic approaches. Such a rigorous scientific model has a tendency to minimize clinical judgment and contextual nuance, what might be called the "human" side of psychiatry. Allen Frances, the architect of the DSM-IV, told PBS that "my concern has been that the ambitions expressed by those working on "DSM-V" would lead to unintended consequences, with many patients being created through new categories or the lowering of thresholds of existing categories, people who probably don't need the treatment that they might receive, but would probably receive if they get a diagnosis."

In an article by John Sorboro, many more concerns are raised. As a practicing psychiatrist and card-carrying skeptic, his sharp words carry a special weight: "Unless the APA takes a dramatic turn and decides to narrow the scope of what it considers pathology and worthy of research and medical treatment, it will be a step backwards for a field already circling the drain due to its poorly conceived cataloging and incoherent theoretical models."

This post has been updated from its original version. It has been edited for brevity. In addition, Allen Frances was misspelled Allen Francis in an earlier version.

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Comments

[oldfox]

03:13 AM on 12/17/2011

I would like to get one of those Skeptic cards. Where can I sign up?

[Lynn Antrim]

05:24 PM on 12/13/2011

Thank you for your watchdog efforts during this process. It comes as no surprise that this is such delicate dance for members of the mental health community. It isn't hard to see where this is going. If the level of resistance over visible injury is any indication and it absolutely is, anguished in mind heart and soul....?

[somewhatodd]

08:40 AM on 12/10/2011

prehaps medical doctors should get together likewise and vote some diseases out of existence.

[Sharon Hanson]

11:58 AM on 12/10/2011

Yes or change it to the proper diagnosis like nephrogenic systemic fibrosis changed to gadolinium associated systemic fibrosis or fibromyalgia changed to poisoned by fill in the blank.

[dopamineboy]

07:34 PM on 12/09/2011

This is a proposed sub-category of ADHD - not making it up..
Sluggish Cognitive Tempo (SCT) is an unformalized descriptive term which is used to better identify what appears to be a homogeneous sub-subgroup within the formal subgroup "ADHD predominantly inattentive." It has been roughly estimated that the SCT population may make up 30-50% of the ADHD-PI population and may even help define a completely new disorder. In many ways, those who have an SCT profile have the opposite symptoms of those with classic ADHD: instead of being hyperactive, extroverted, obtrusive, and risk takers, those with SCT are drifting, introspective and daydreamy, and feel as if "in the fog". They lack energy to deal with mundane tasks and will consequently seek things that are mentally stimulating because of their underaroused state, an intense craving for emotional and intellectual stimulation.
....Basically it means they find school boring.

[Sharon Hanson]

02:03 PM on 12/10/2011

Or they have otherwise been poisoned but my guess is they find school boring.

[Natasha Tracy]

03:03 PM on 12/09/2011

The DSM is an extremely complex document as it deals with an extremely complex organ - the brain. We don't know how the brain works and so trying to outline its dysfunction in a document is extremely difficult if not impossible.

Nevertheless, we must try in order to help people who are really sick. I can only speak from the point of view of a person with bipolar disorder, but the diagnostic criteria are extremely useful, not perfect.

Additionally, the DSM-V is attempting to make the diagnosis of bipolar more akin to real-life cases. It is doing this through complexity. But this isn't a surprise as bipolar is a complex disease and presents in many forms.

Some may argue in doing so they are "making" illnesses but that isn't the intention. The intention is to represent clinical and scientific reality.

Nevertheless, I suspect the DSM will be streamlined before it is released due to the public outcry about the current revisions. As is mentioned in the article, DSM criteria is most useful in time-relaxed structured interviews and in reality few people have the time for that. The same will be even more true if the new revisions come into being.

We are walking forward but the path is murky at best. It doesn't mean there still isn't some forward movement, however.

- Natasha Tracy

[jack Winn]

02:27 AM on 12/12/2011

Neurology addresses the brain as an organ. Psychology addresses the mind, although its practitioners commonly let their subjects conflate the issue for the purpose of marketing.

The DSM was designed and is maintained as a billing and documentation device, and its diagnoses are voted in and out by committee. Yet it is the closest thing to a reproducible standard in the field.

There are no objective markers or tests for a DSM dx, and the reason is simple - all dx are identified by behavioral patterns, none of which are measurable. DSM dx are 'spectrum disorders', meaning they can exist in any degree, as any casual reader can see.

How could so many people believe in something if it wasn't true? Most of the world believes in one religion or the other, most of which assert that it alone is true - because they want to believe.

[Natasha Tracy]

01:50 PM on 12/12/2011

The subjects merge because the subjects merge, not simply because of marketing.

There are studies upon studies that note the biological differences between the depressed brain and a well one, a schizophrenic brain and a well one, a bipolar brain and a well one. Moreover, there is now a blood test both for schizophrenia and for depression. Both are in their clinical infancy, but their use is something we are rapidly approaching.

There are objective markers in psychiatry in the same ways as there are in other sciences. A slice of tissue is only cancerous because the cancerous cells meet a certain threshold, just like symptoms only represent a disorder when they meet a certain threshold in psychiatry as well.

- Natasha Tracy

[jack Winn]

12:51 AM on 12/16/2011

Here are some problems with current US psych practice - and I use that term to save bandwidth without needing to explain the difference between psychiatrists and psychologists, since both refer back to the same model anyway. (If you are offended, I suggest you lose the chip on your shoulder.)

1) DSM dx are behavior patterns. There are NO objective markers. No, "significant bereavement" is not measurable, reproducible or objective. Some people grieve for their hamsters, others are happy to see their mother die (and possibly justifiably). Some think one thing is significant, others don't - and if psychs had a measure, they would publish it. But they don't.

2) So a DSM dx is an opinion of objectionable behavior. That's what all those symptoms are about. There's no "abnormality" because inter alia, there's no definition of normal - is there?
It's all somebody's opinion.

3) So how are these opinions formed? Almost always, they are made based on hearsay descriptions of out-of-office behavior by either (a) a self-referred person who is there because both of you suspect their perceptions are unreliable, or (b) the allegation of an absent 3rd party agency with its own interests. I have seen major HMOs use 3d party pre-printed questionnaires to poll teachers on DSM standards, so please dont say you need to be a shrink to recognize a 'symptom'. The shrinks routinely get their input from laymen.

CONTD

[Vajara]

02:17 PM on 12/09/2011

THE DSM is a scam with little if any scientific evidence of reliability and validity. Persons taking multiple meds will experience side effect beyond the knowledge of the doctor or scientist. It is a scam that puts a label on a human being as having a special disorder for life and will be given multiple drugs to reportedly ease the pain or anxiety. NOT!!! Long ter use of the antipsychotics shows that the frontal lobe of the brain is reduced in size, similar to lobotomies...psychiatry of the 60's and 70's. Now the mental health patients can give themselves the lobotomy and feel as though they have a disease or illness. Thousands, if not millions of our vets and given a Post Traumatic Stress label for life which may be the # 1 reason for their suicides...the other is related to the multiple drugs prescribed that do nothing for these catastrophic whole body, mind, spirit and social injuries....a natural response or reaction to war trauma.

[Frank-Landfield]

08:22 AM on 12/09/2011

I hear voices.
:-)

[jack Winn]

11:36 AM on 12/09/2011

what are they saying?

[archstantn]

01:12 AM on 12/09/2011

A recent report claims that over twenty percent of American adults now receive prescription pharmaceuticals for a variety of psychiatric disorders, including depression and anxiety. As the number and type of "disorders" increase, the figures for "med" use, should indeed rise proportionately. Since the logic underlying this drug use is based on the premise that psychiatric disorders are, in fact, chemically based, one could reasonably wonder how the "natural" human brain chemistry got so flawed in the first place. I find it hard to believe that after about four million years of human evolution, suddenly, one in five of us are in dire need of the assistance of medication which alters this chemistry. Add to that, the fact that "informed consent" is pretty much a joke, and it would seem that some kind of government investigation or review is in order.

[reading2009]

01:11 AM on 12/09/2011

The whole DSM concept may in fact be invalid. People don't always fit into neat little categories, but diagnosis is necessary in order to have any kind of standardization. One should, however, always take these diagnoses with a grain of salt.

[jack Winn]

11:37 AM on 12/09/2011

The DSM was and is intended as a billing catalog. Diagnoses are established by committee vote.

[somewhatodd]

08:43 AM on 12/10/2011

that's exactly right. the real committee deciding who's really got what or who doesn't is in the insurance office.

[oldfox]

03:19 AM on 12/17/2011

Not me. I have hypertension.

[paulacaplan]

11:43 PM on 12/08/2011

Great article. Members of our PLAN T (Psychiatric Labeling Action Network for Truth) Alliance, concerned about the lack of solid science in psychiatric diagnosis, as well as the vast array of ways that people have been harmed because of getting a psychiatric label, have for more than a quarter of a century worked to try to stop the harm and educate the public about the unscientific nature of these categories. A petition representing more than six million people and sending documentation to the DSM editors of edition III-R (headed by Robert Spitzer) in the mid-1980s and edition IV (headed by Allen Francis) in the early 1990s failed to stop the juggernaut, which brings huge profits for the American Psychiatric Association, the lobby group that publishes it. Recognizing that more action is now needed, the PLAN T Alliance has posted the following and hope you will consider signing and posting, forwarding, tweeting, etc. This is important for anyone who cares about the lives being ruined in the name of science that is really junk science.

Boycott the DSM
http://www.change.org/petitions/boycott-the-dsm

Call for Congressional Hearings about Psychiatric Diagnosis
http://www.change.org/petitions/everyone-who-cares-about-the-harm-done-by-psychiatric-diagnosis-endorse-the-call-for-congressional-hearings-about-psychiatric-diagnosis

[paulacaplan]

11:49 PM on 12/08/2011

And for more information, see:
psychdiagnosis.net
MindFreedom.org
Both of the above have stories about the way psychiatric diagnosis has done serious damage.
For the story behind earlier editions of the DSM, see They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal (available through major online booksellers), in which I document the story from the inside of the DSM enterprise, because until I resigned in horror at the way science was misused, ignored, and lied about, I was a DSM consultant. And in the Association for Women in Psychology's book, Bias in Psychiatric Diagnosis, you see more examples of problems and harm. In addition, on the Paula J. Caplan blog on Psychology Today, you will find many essays about the reasons for alarm about the way DSM-5 seems to be going.

[Bellanova]

12:50 AM on 12/09/2011

Good to see you here, Paula, and always good to hear your input, especially on this topic!

Happy to be your first HP fan.

[paulacaplan]

01:30 PM on 12/09/2011

Thank you. I'd love to know who you are if you want to say. Hoping you will help spread the word about the petitions, please.

[livingbettertherapy]

08:16 PM on 12/08/2011

Diagnosis from the DSM IV-TR can be a two edged sword. It can sometimes be useful but it isn't foolproof and can lead to false positives. The DSM is not a holy book. It will always be subject to change because of new scientific studies. A DSM diagnosis can also become a self fulfilling prophecy for some patients that contributes to their dysfunction. Don't give up hope. Skilled therapists and counselors with real world clinical experience know that many who have been branded with DSM labels can get better, change and grow.

[paulacaplan]

01:40 PM on 12/09/2011

As you will see in the references I cited in my earlier comment, the DSM does NOT change because of good scientific studies. I was on two of their committees when Allen Francis was in charge, and I resigned because I am a research methodology specialist and was horrified by how fast and loose they play with the science. When people get better, it is in spite of the labels, not because of them.

[livingbettertherapy]

03:13 PM on 12/09/2011

Excellent point. Thanks for sharing an insiders view and empowering people. Your candor gives people hope that DSM labels frequently take away.

[Tim The Enchanter]

07:32 PM on 12/08/2011

http://www.southparkstudios.com/clips/103440/drug-free-treatment

[Tim The Enchanter]

07:27 PM on 12/08/2011

I suspect "Liberal Personality Disorder" will be in there, which is probably why there are a lot of people suddenly saying DSM isn't that valuable any more.

LPD is related to Narcissism, but differs primarily in that NPD is caused by a feeling of overwhelming insecurity, LPD is caused by a persistent feeling that "life isn't fair", generally caused by being a second or third born child, or a feeling of being unfairly treated by parents, teachers or others during formation.

[Syllogizer]

08:27 PM on 12/08/2011

If LPD is related to Narcissim, why aren't the narcissists among the Republican candidates acting more like Liberals? They are instead falling over each other to fawn on the far right -- who have their own mental disorders.

[Tim The Enchanter]

09:02 PM on 12/08/2011

In many ways they do. But the difference is that LPD is basically a prerequisite for "liberalism", meaning that pretty much 100% of them are afflicted with it, so essentially 20% of the population. Those that are not are independents, libertarians, conservatives.

[oldfox]

03:26 AM on 12/17/2011

Someone asked me why I bother to vote.

I have a duty with a 138 IQ to neutralize the vote of a 62 IQ Democrat.

[reading2009]

01:12 AM on 12/09/2011

haha

not.

[Tim The Enchanter]

09:38 AM on 12/09/2011

Denial is one of the traits of both LPD and NPD.

[chinohillster]

04:02 PM on 12/08/2011

Unfortunately, the DSM-IV, and much (not all) of psychiatry/psychology has been the victim of a 'physical-pharmacological' approach to treatment and not a 'relational' one. Much (not all) therapy is successful because of a _therapeutic relationship_ between a patient and therapist, or patient and a therapeutic community. 'Relational' requires _time_, _effort_ and _money_, all of which insurance companies are _loath_ to give up - better to hand a SSRI/SSNRI to someone in a 5-minute visit instead of spending weeks, months or even years connecting to/with a person.

Better to use _prisons_ for those whose pain results in damage to themselves and injury and/or death to others.

Actual solutions to many mental illnesses (and I do not discount those persons with organic issues resulting in behavioral problems) would require a hard look at societal institutions such as family, school, work - how their organization and function contributes to mental illness for many who cannot negotiate them.

[reading2009]

01:12 AM on 12/09/2011

hear, hear!

[John Bobrowski]

03:50 PM on 12/08/2011

In my opinion, DSM IV is a reaction to Mental Health Parity and Addiction Equity Act of 2008 and the absence of "medical necessity" screens that can operate to define the limit on "medically necessary" cognitive behavioral therapy. It appears that many disorders that are not treatable with prescription drugs are being written out of DSM IV so as to avoid what could be very substantial legally mandated insured cognitive behavioral treatment plans. "Medical treatment" have been so studied that "medical necessity" can be defined with statistical precision.

While I am only a DSM IV voyeur, it appears to be driven by drug and insurance interests. If that is true, it is a tragedy and an object lessons to how payers and those being regulated have co-opted both private and public regulatory processes.

[jf12]

09:33 PM on 12/08/2011

Yes, precisely. If it ain't cheaply fixable, then it ain't broke.

[Bellanova]

12:54 AM on 12/09/2011

That's a very good way to put it.

[huru kidding]

11:48 PM on 12/08/2011

Nice theory but the DSM IV was published in 1994, well before 2008. If you are referring to the upcoming DSM V no one knows what the final version will look like.

[John Bobrowski]

12:33 AM on 12/09/2011

You can see the trend.

The bad reference to the version was inadvertant. The point still is valid. No one has suggested a solution yet. And continuing to permit treating professionals to determine medical necessity is views by payors as a potential money printing machine.

Perhaps someone like you -- who is clever enough to point out my incorrect DSM reference -- can design the solution -- and maybe even publsh it under your real name.

[Bellanova]

12:54 AM on 12/09/2011

John's points still stand. If anything, the trends he's described have only solidified since DSM-IV. See Paula Caplan's most excellent comments above.