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DSM-5 Is Diagnosed, With a Stinging Rebuke to the APA

The regrettable history of the DSM should not be whitewashed.

American Psychiatric Association
Source: American Psychiatric Association

Earlier this month, when the American Psychiatric Association decided at its annual meeting to drop two of its more-controversial proposals (“attenuated psychosis syndrome” and “mixed anxiety depression”), the organization might have imagined that throwing a bone to its critics would end the controversy that DSM-5 has excited.

True, initial responses from critics hinted at frank and understandable relief. “We have dodged bullets,” former DSM-IV editor Allen Frances cheered on his PT blog as he broadcast the “wonderful news.” “DSM-5 finally begins its belated and necessary retreat.”

But a funny thing happened on the manual's already potholed road to publication. “Far from mollifying their critics,” Geoff Watts noted in the British Medical Journal three days ago, “these concessions have served to ignite a further and still more vituperative barrage of dissent.”

Among the fiercest critics quoted is Mark Rapley, a clinical psychologist at the University of East London, who puts it this way: “The APA insists that psychiatry is a science. [But] real sciences do not decide on the existence and nature of the phenomena they are dealing with via a show of hands with a vested interest and pharmaceutical industry sponsorship.” Despite commending the DSM-5 authors for “reconsidering some of their most unfortunate mistakes,” clinical psychologist Peter Kinderman of the University of Liverpool adds that the manual remains, at bottom, a bad and faulty system. “The very minor revisions recently announced do not constitute the wholesale revision that is called for,” he is quoted as saying. “It would be very unfortunate if these minor changes were to be used to suggest that the task force has listened in any meaningful way to critics.”

In “Diagnosing the DSM,” a highly read op-ed in the New York Times three days ago, it was Frances’ turn to elaborate, and as he did so the APA and the diagnostic manual came in for stinging rebuke. “DSM-5 promises to be a disaster,” he warned. “Even after the changes approved this week, it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription.”

Frances called “attenuated psychosis” a “reckless proposal that would have exposed nonpsychotic children to unnecessary and dangerous antipsychotic medication and another that would have turned the existential worries and sadness of everyday life into an alleged mental disorder.”

He added that other proposals—including to formalize “premenstrual dysphoric disorder” as a bona fide mental disorder and to add other questionable ailments such as “hypersexual disorder” and “disruptive mood dysregulation disorder”—“could potentially expand the boundaries of psychiatry to define as mentally ill tens of millions of people now considered normal.”

Frances chided his colleagues for their “diagnostic exuberance,” even as he skated rather quickly past the dozens of dangerous and poorly considered childhood disorders (including juvenile bipolar disorder and lowered thresholds for ADHD) that the previous edition had added on his watch under his editorial eye. “Experts always overvalue their pet area,” he explained, “and want to expand its purview, until the point that everyday problems come to be mislabeled as mental disorders. Arrogance, secretiveness, passive governance, and administrative disorganization have also played a role.” Indeed they have.

Given Frances’s significant role now as a whistleblower on psychiatric mislabeling and arrogance, and the many well-informed columns and posts that he's published in the last year alone on the dangers of “diagnostic inflation” (his term in the NYT), I welcome and of course second his call to “break up the psychiatric monopoly” by establishing the “equivalent of the Food and Drug Administration to mind the store and control diagnostic exuberance.”

It’s nonetheless unfortunate that in criticizing the APA so forcefully for its still-limited response to DSM-5 criticism, Frances turns to earlier editions to shore up a perception that the manual rests on credible foundations. The result, unfortunately, is close to whitewashing over the fierce, protracted battles that met their publication also, which Frances glosses, amazingly, as akin to cocktail chatter:

DSM-3 stirred great professional and public excitement by providing specific criteria for each disorder….. Surprisingly, [the edition] also caught on with the general public and became a runaway best seller, with more than a million copies sold, many more than were needed for professional use. Psychiatric diagnosis crossed over from the consulting room to the cocktail party. People who previously chatted about the meaning of their latest dreams began to ponder where they best fit among DSM’s intriguing categories.

Dr. Frances: you forgot to mention the years of intense intra-psychiatric wrangling, likened by some to professional warfare, and the mountains of angry correspondence that DSM-III generated from bitterly opposed critics whose perspectives were consistently and conveniently ignored. You omitted the colleagues who resigned from the DSM-III task force, complaining that the dozens of equally poorly considered proposals (many of them later approved as mental disorders) had left them with an “Alice in Wonderland feeling.”

You’ve passed over that Harper’s Magazine lampooned DSM-III as the “psychiatric handbook [that] lists a madness for everyone.” Your analogy about cocktail chatter also bypasses the colleagues serving on the DSM committees who later admitted to the New Yorker magazine in 2005: “There was very little systematic research [in what we did on DSM-III], and much of the research that existed was really a hodgepodge—scattered, inconsistent, ambiguous.” These are psychiatrists who accused you and Robert Spitzer in the 1970s, 80s, and 90s of the exact same arrogance and intransigence for which you correctly fault the APA today. This is all documented in my book on DSM-III and later editions, Shyness: How Normal Behavior Became a Sickness, based as it is on the APA's own archive of records and interviews with many of the key players. On your and Dr. Spitzer’s watch, the DSM became almost seven times longer than its first edition, with almost three times as many disorders listed.

I understand strategically why focusing on the most egregious problems in the next edition should be the next critical step. I too cheer the removal of “attenuated psychosis syndrome” from DSM-5 even as I wonder at how much effort and energy that removal finally took, and contemplate in great dismay that premenstrual dysphoric disorder could still become a formal mental disorder next year, after Spitzer snuck it into the appendix to DSM-IIIR and then called its diagnostic code the result of “a printing error.”

But as we challenge the diagnostic madness of the APA, let’s not whitewash the unillustrious history of its product, the DSM. That history needs reviewing and carefully remembering, warts and all, if we’re to grasp why the next manual is likely to make an already desperate situation fifty times worse. Follow me on Twitter: @christophlane