Is the DSM Turning into a Train Wreck?

Should it be torn into pieces or just quietly forgotten?

Posted May 21, 2015

I’m just back from the annual meeting of the American Psychiatric Association. It was held this year in Toronto, and one of the big questions was whether DSM-5 should be torn into pieces or just quietly forgotten?

Well, I’m exaggerating. But there was a panel on DSM where three of the four papers were scathing about it and the two discussants had little good to say. 

A highpoint was when one of the discussants, who had played a prominent role in the affective disorders panel of the Task Force, said that he had approved of only half the material in the depression and bipolar chapters. The rest had been enforced upon the panel from above. “There were just too many cooks,” he said. And they all had their ladles in the soup, stirring it about. The outcome was political rather than scientific.

The panel members went into their work with the idea that this time they were really going to let “science” be their guide, and they came out of it shaking their heads.  Bureaucratic committees in the APA head office had really decided the final classification of diagnoses, and it had little to do with science.

Of course the audience was riveted to hear this confession of political meddlesomeness --- from one of the key figures in the whole process! For me, it wasn’t a big surprise because I had heard all along what a travesty the whole thing was turning out to be – and Allen Frances, the editor of DSM-4 – had alerted people in advance that there was trouble ahead. But still . . .

And then, when I turned on my Twitter feed this morning, I found this very interesting post from a counselor-hypnotherapist: “The classic 5 symptom areas, separate melancholia and the idea of ‘nerves’ works in practice. My clients get it right away.”

He was talking about the classification of mood disorders and nerves that I had laid out in my book How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown, that Oxford University Press published in 2013. I said there are two separate kinds of depression: melancholia and nervous illness. The symptoms of nervous illness tend to be dysphoria, anxiety, fatigue, somatic symptoms (like phantom aches and pains), and a tendency to obsess about the whole thing. Learning that his patients grasped this immediately was a nice way to start my day. Most of them would have had nerves.

The second kind of depression is melancholia, which is very different from nervous illness: profound sadness, slowed thinking and movement (or an anxious acceleration of pacing and fearful utterances), and inability to experience joy or pleasure of any kind in life. The risk of suicide is high. 

Suicide is not unknown in nervous illness, but the risk seems to be much less.

Is this brilliant on my part, separating melancholia from nerves? Not at all! I was simply writing what most psychiatrists believed before the DSM disaster. Psychiatry had always been aware of those two depressions, abolished by fiat in DSM-3 in 1980.

The concept of “nerves” meant that such symptoms as anxiety, demoralization, and fatigue had always found a group home together, before modern psychiatry decided to break up the group home and put its denizens out on the street as separate “disorders.”  (Psychiatry actually lost interest in fatigue entirely – a hugely important symptom in the patients’ world.) All these supposedly separate disorders blend into one another and all respond to the same treatments.

Psychiatry is rapidly losing faith in the DSM. The National Institute for Mental Health has already rejected it as a symptom guide for research. The Europeans are openly skeptical. Yet the trainee psychiatrists are still obliged to memorize it and pretend that the DSM illnesses (“bipolar disorder,” “major depression,” and “social anxiety disorder”) are real.

Let me say in parentheses that the two kinds of depression mentioned above are very real, but that it makes no sense to classify depression on the basis of “polarity” – whether the mood swings or not. Senior clinicians know that sooner or later, most patients with unipolar depression (“major depression”) will develop an episode of mania or hypomania.  Does that therefore change the diagnosis? Of course not.

When I heard this very senior figure from the affective disorders panel say in public that he thought much of the section was a pile of crap imposed from above and that he couldn’t endorse it, I thought, “There’s trouble ahead.” Stay tuned.