Mood Swings

A psychiatrist surveys the mind and the wider world

Death by DSM Part II

Not guilty by reason of "adjustment disorder."

I have written previously about the dangers of the “pragmatic” approach to DSM revisions. They literally can be deadly. In my debates with the leader of DSM-IV on this website, he has argued that “pragmatism” should trump science ("It seems clear to me that pragmatic concerns for patient welfare always trump 'science'..."). This means that what the DSM leaders think are in the best interest of the profession and the public should supersede whatever the scientific evidence shows. ("Much has been written about the 'validators' of psychaitric diangosis...To my mind, by far the most important validator is how will any decision help or harm patient care....") This is because those leaders think that science is always debatable and controversial, and thus their opinions, as leaders who care about the public interest, are better than the views of scientists, who only care about their favorite theories.

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I disagree with this cynicism. I think science is more objectively valid than the opinions of DSM leaders. I also think that we have much more probabilistically valid scientific evidence than DSM leaders allow. For instance, we know that if a patient gets manic on antidepressants, then that patient has over 99 percent likelihood of NOT having “major depressive disorder” (MDD). But in 1994, without any scientific evidence to support it, the DSM-IV leadership made it verboten to diagnose bipolar disorder in the setting of antidepressant-induced mania alone (i.e., mania had to be spontaneous). This has led, as I have shown, to actual deaths of individuals who were misdiagnosed as having MDD, based on the false “pragmatism” of DSM-IV, and given antidepressants, which caused mixed/manic states, which led to suicide.

Now there is another example of death by DSM, this one related to a broader consequence of unscientific “pragmatism." Some defend the “messy, atheoretical” DSM system based on the view that we don’t know what causes what. The consequence is that DSM uses the term “disorder” for all conditions. Schizophrenia, a condition known for over a century with a huge amount of biological evidence regarding its pathophysiology, is a “disorder,” just as being unhappy in a difficult marriage is a “disorder,” called “adjustment disorder.” If you find out your wife is having an affair, and then you kill your children, stabbing them 46 times, notifying your mother, and cancelling your appointments that day before you carry out the murders, you have a “mental disorder” and are not responsible for what you did. This apparently happened in a controversial legal case in Quebec, in which a physician was found not guilty of murder of his children because he was diagnosed in court with the "mental illness" of an  “adjustment disorder” caused by his marital break-up. He had no prior evidence of depression or other known pscychiatric illnesses; after his acquittal, he has been mandated psychotherapy but no medication treatment for any known classical psychiatric illness (such as manic-depression or severe recurrent depression).

The practice of medicine is a serious moral affair. One can cure, and one can kill. "How will any decision help or harm patient care?" If we think we know better than science, we would do well to think about harmful consequences of false DSM-"pragmatism" such as this case. 

Nassir Ghaemi, M.D., M.P.H.,

is Professor of Psychiatry at Tufts University School of Medicine, and Director of the Mood Disorders Program at Tufts Medical Center in Boston. more...

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