How Everyone Became Depressed

The rise and fall of the nervous breakdown

The Coming Battle Over DSM-5

A wave of opposition is building against the new edition of psychiatry's bible.

"DSM" is the Diagnostic and Statistical Manual of the American Psychiatric Association. It is the international bible of psychiatry, and the fifth edition is due to be launched at the APA's annual meeting in San Francisco this May.

The APA anticipates that it will be received with shrieks of enthusiasm and shouts of praise – after all that work, years of committee meetings and horse-trading about diagnoses.

But guess what?  May not happen.

A wave of international anger is building agains the whole DSM concept and the fifth edition in particular.

There are three problems with the concept.  One is that the diagnoses are determined by consensus, and that means bargaining:  I'll give you your diagnosis if you give me mine.  This is a fundamentally unscientific way to proceed. The speed of light was not determined in a consensus conference.

The second problem is that a list of symptoms is used to make a given diagnosis. If you meet the criteria for three out of six symptoms, you qualify for a really serious kind of depression called melancholia.  OK.  What are those six?  It would be tedious to list them all here (and you can find them in the current edition, DSM-IV-TR on p.420). But if you feel worse in the morning than the afternoon, wake up too early, and feel guilty about something, you can qualfy.

Really?

Melancholia is a terrible illness that has echoed to us down the ages as putting you at risk of suicide, demobilizing you, destroying your marriage, wrecking your work performance, and leaving you curled in a fetal ball of pain in your bed. Novelist Willian Styron describes it movingly in Darkness Visible (1990). What he experienced bears no relationship to what is described in DSM.

An alternative approach would have been to describe in a prose vignette the typical features of a psychiatric illness, then add on a couple more vignettes to cover the main variations. This is essentially what Emil Kraepelin did in his famous psychiatry textbooks in the 1890s that represents the beginning of modern psychiatric diagnosis (and what Freud did as well, in such beautifully crafted prose that one loses track of the possibility that his ideas might all be fictitious).

The third problem is that many of the diagnoses in DSM lack a sound scientific basis. They are more the products of individual whim or efforts by psychoanalysts to salvage something from the ruins of Freudianism. Schizophrenia, bipolar disorder and major depression are the diagnoses at the heart of the DSM system, and none of the three correspond to the real illness that patients have in the real world:

  1. There is no single psychotic illness called "schizophrenia" but a variety of diseases that cause chronic psychosis.
  2. It is pointless to classify depressions on the basis of polarity (unipolar major depression vs. bipolar disorder). So bipolar disorder is simply a way of saying that serious, melancholic depression is often complicated by manic illness.
  3. "Major depression" is certainly a heterogeneous category which lumps together the two depressions that psychiatry has known since time out of mind: melancholia and nervous disease (called more recently "reactive depression," "neurotic depression," et cetera).

These are all widely shared thoughts, and those who share tham have no use for the whole DSM concept.  I think we will not see a DSM-6.

 

Edward Shorter, Ph.D., is the Jason A. Hannah Professor in the History of Medicine at the University of Toronto.

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