Joel Paris, MD, is an eminent psychiatrist, and is also a Professor of Psychiatry at McGill University in Montréal. He has recently written a very timely book titled: The Intelligent Clinician’s Guide to the DSM-5, published by Oxford University Press.
I have placed an order for this book through our local inter-library loan system, and when it comes in, I’ll publish a review. But in the meantime, Dr. Paris has posted on Oxford University Press’s website a brief essay to promote the book. The essay has lots of interesting aspects, and I thought it might be helpful to examine it in some detail.
The opening sentence in the essay is:
“The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a classification of all diagnoses given to patients by mental health professionals.”
Note that Dr. Paris did not say that the DSM is a classification of mental disorders, which is what its name would imply. Rather, he’s saying it’s just a sort of catalog of psychiatric activity. What Dr. Paris is doing here is distancing himself from the notion that the DSM is a classification of conditions existing in clients. But the essential point that the APA and psychiatric thought leaders have been pushing for decades is that the DSM is such a classification. But now the cat is out of the bag: DSM is a pile of rubbish and, everyone wants to get off the ship. We’ve seen a great deal of this psychiatric side-shuffle recently.
In his second paragraph Dr. Paris begins:
“DSM-5 is not, as sometimes claimed, “the bible of psychiatry”. It is not based on a thorough understanding of the causes of mental disorder, which remain largely unknown.”
Bearing in mind that “mental disorder” is simply the name that the APA gives to human actions or feelings that entail a significant level of stress or incapacity or pain or risk of incarceration, it is difficult to understand Dr. Paris’s contention that the causes of these problems are “largely unknown.”
In my experience, if you ask a person who is depressed, for instance, why he is depressed, he can usually give a pretty coherent answer. He can tell you the cause of his depression. Similarly with the condition known as PTSD, the individual can recount the precipitating traumatic incident, which common sense suggests is the proximate cause of the disturbing memories.
So when Dr. Paris says that the causes of mental disorders are largely unknown, he means the putative biological causes, though he doesn’t make this explicit. Once again, it’s a case of psychiatry discounting and even disregarding what clients say about their problems, and imposing a bio-psychiatric perspective.
Dr. Paris continues:
“What DSM does is to allow mental health professionals to communicate with each other by listing criteria by which diagnoses can be made reliable.”
This is a frequently heard theme. But given the poor reliability figures from the DSM-5 field trials, it simply isn’t true! A more accurate analogy would be that when psychiatrists communicate, some speak in English, others in German, others in Spanish, others in various mixtures of various languages, etc… The common language argument is an attempt on the part of psychiatry to salvage something from the DSM, but the fact remains – it isn’t even a common language.
“Unfortunately, the use of certain diagnoses is so widespread that people get the impression that categories in psychiatry are as real as hepatitis or multiple sclerosis. They are not.”
With which, of course, I wholeheartedly agree. Dr. Paris, however, makes no mention of the fact that for the past two or three decades psychiatrists have been saying otherwise. It would have been nice if he’d acknowledged this widespread and persistent deception.
Then he makes a particularly interesting point:
“They [DSM diagnoses] are simply convenient ways of describing what clinicians see in practice.”
This sounds very simple and innocent, but it ignores the well-studied and widely known fact that preconceived ideas influence perceptions. To put it simply: if you’re looking for the things listed and described in the DSM, then there is a very high likelihood that you will find these things and – more importantly – that you will miss or discount other things. If all a psychiatrist is seeking in the initial interview is a “diagnosis,” then that’s what he’ll find. What he won’t find is the complexity, individuality, and uniqueness of the person. And if he believes that these “diagnoses” are brain illnesses, he will also “see” a need for drugs.
DSM is, and was designed to be, normative. It is not simply a record of what psychiatrists see. It is their professional manual that tells them what to find. And for the past 60 years, that’s exactly what they have been doing: reducing people to DSM codes and using these codes to justify pouring toxic chemicals into their brains.
Back to Dr. Paris:
“The DSM system has led to an inflated prevalence of certain disorders, sometimes producing diagnostic epidemics. These problems affect some of the most common disorders in practice. Thus “major depression” is a very disparate collection of signs and symptoms that cannot be used to determine the correct treatment. Bipolar disorder is being diagnosed in patients who do not have its classical features, and has even been applied to young children. Attention deficit hyperactivity disorder (ADHD) has no definite boundaries, and is being greatly over-diagnosed, both in children and adults. Autism spectrum disorders, once considered rare, are now being seen as among the most common of all conditions that professionals see.”
This is all very true, of course, and you might even be wondering which side Dr. Paris is on. But his final paragraph raises some concerns:
“The DSM system can be described as flawed but necessary. Clinicians need to communicate to each other, and even a wrong diagnosis allows them to do so. However it will require many decades before we know enough about mental illness to produce a truly scientific classification.”
Note the phrase in the second sentence: “…even a wrong diagnosis allows them to do so” (i.e. communicate). He’s clinging desperately to the DSM, even though it’s invalid. A great many psychiatrists today are stuck on this particular cusp. They have seen their treasured manual pounded, even by their very own thought leaders. But it still feels safe. It still offers them the hope that they are real doctors, making real diagnoses, and providing real medical treatment.
I must confess to having significant misgivings in picking on Dr. Paris’s work. He is by no means a dyed-in-the-wool bio-psychiatrist. For instance, he has long advocated talk-therapy rather than drugs for the behaviors known as borderline personality disorder, and in a recent paper on overuse of drugs he had this to say:
“Many antidepressants are said to work by fixing “chemical imbalances” in the brain. But no consistent chemical abnormality has ever been found in the brains of patients with mental disorders…”
“…doctors should stop all contact with the drug industry and refuse to attend industry-sponsored ‘continuing medical education’ events.”
My guess is he’s struggling with what’s going on in his chosen profession – what decent person wouldn’t – and is trying to salvage what he can. But there were some subtleties in his paper that I felt warranted elucidation.