On 3-4 June, the Institute of Psychiatry in London hosted an international conference to mark the publication of DSM-5. On June 10, Sir Simon Wessely, a department head at the Institute, published a paper called DSM-5 at the IoP. The paper is a summary of the conference proceedings, and also, in many respects, a defense of DSM-5. The article touches on many issues that are central to the current anti-psychiatry debate, and for this reason, I thought it might be helpful to take a close look at the piece.
WHY IS DSM-5 CONTROVERSIAL?
Sir Simon expresses surprise that DSM-5 has been so controversial. He discusses this matter from various perspectives, but in my view he misses the essential point.
He writes: “The DSM is nothing more than a list of psychiatric disorders, accompanied by descriptions of disorders and explicit criteria for their diagnosis.”
It might be argued that this statement is true in the literal sense of the term, but it ignores the fact that the DSM is also (and perhaps more importantly) the primary source of legitimacy for the unproven assumption that all serious human problems are in fact illnesses, and are best “treated” by medical methods.
The contention that the DSM is nothing more than a list of psychiatric disorders is a bit like saying that Malleus Maleficarum (1487) is nothing more than a list of signs by which witches can be identified, and ignoring the fact that it was also the authoritative confirmation that witches really did exist and really did cause a great deal of mischief. For almost three centuries, Malleus Maleficarum served as the justification for murdering eccentric and otherwise unpopular women. In the same way, today DSM is used throughout America and other countries to justify and legitimize the drugging (sometimes forcibly) of millions of people, frequently with horrendous side effects.
But Sir Simon doesn’t seem to be aware of any of that.
Nor is this aspect of the DSM’s identity an accident. In 1952, when the first DSM was published, I don’t think it would be an exaggeration to say that psychiatry was a laughing stock among medical specialties. As the latter increasingly aligned themselves conceptually and practically with science, psychiatry wallowed in the decidedly unscientific notions of psychoanalytic theory and the brutal unvalidated “treatments” of the asylums.
Psychiatry desperately needed to get its act together and establish that it was a real medical specialty. It is arguable that this may have been a secondary agenda in 1952, but by 1968 – the year DSM-II was published – this aspect had become more urgent. There were two reasons for this. Firstly, the pharmaceuticals were coming on stream, and psychiatrists needed bona fide illnesses for which to prescribe these products. Secondly, behavior therapy was experiencing a great deal of success in the mental hospitals, especially with the more “challenging” cases, and was beginning to pose a significant challenge to psychiatric hegemony. By unequivocally medicalizing the presenting problems, psychiatry legitimized the widespread drugging of its clients, re-established its supremacy, and at the same time marginalized and subordinated behavior therapy.
The notion that all problem behaviors and emotions are illnesses is a spurious and unproven assumption, but it is an assumption that has served psychiatry (and incidentally their pharmaceutical allies) well for over four decades.
And that is why there has been so much controversy surrounding the publication of DSM-5. The negative press has arisen, not because there is anything strikingly new or different about DSM-5. The criticism stems rather from the fact that it is just more of the same. It’s the same lie being trotted out: that depression, misbehavior, mania, disruptiveness, temper tantrums, anxiety, etc., are real illnesses – just like diabetes. And that this lie is still being promoted despite four decades of failed research looking for the biological etiologies that would save this sorry theory.
In the meantime, the concept of mental illness is just another spurious assumption which would have been scrapped long ago but for the fact that it serves the interests of psychiatrists and their pharmaceutical allies.
The IoP conference could have addressed this – the central issue of the debate. And Sir Simon could have written about this. But instead, the matter was ignored.
EXPANSION OF DIAGNOSTIC ACTIVITY
Instead, Sir Simon wrote about the fact that the number of diagnoses has been quietly increasing, but that thankfully DSM-5 has reversed this trend. Does he seriously imagine that fewer people will be assigned psychiatric “diagnoses” under DSM-5 than under DSM-IV?
Sir Simon also concedes that there has occurred what he calls “psychiatric mission creep” – “the medicalization of the normal, the eccentric and the odd.” Bravo! But it’s still not the main issue. Medicalizing severe problems is just as spurious as medicalizing trivial problems.
Sir Simon goes on to reassure us that: “Concerns that the DSM-5 would continue in the inexorable march of medicalization by adding grief and bereavement to the list of human emotions that now required treatment were misplaced.” I find myself at a loss as to how he can possibly know that. Grief and bereavement are already being widely medicalized under DSM-IV, and this trend is almost certain to expand, given the specific easing of criteria in DSM-5.
Continuing on the topic of diagnostic expansion, Sir Simon writes:
“For most psychiatrists, claims that we are embarked on emotional world domination, seeking to extend our boundaries, populations and wallets further and further sounds hollow and frankly laughable when most face the most stringent cuts to services in a lifetime.”
This quote warrants some scrutiny. What Sir Simon is saying here is:
1. Our critics contend that we are pursuing emotional world domination. Ha, ha.
This is essentially an attempt to ridicule the opposition. Addressing our concerns openly and honestly would have been more productive.
2. The opposition say that we are seeking to extend our boundaries, populations, and wallets.
Psychiatrists have been, are, and apparently plan to continue extending their boundaries, populations, and wallets. And, with the help of pharma dollars, have been remarkably successful in these areas. Juxtaposing this statement with the world domination quip is a standard spin doctor trick, well-known to politicians.
3. The contentions of our opponents are hollow and laughable, because … get this … because our budgets are being cut due to governmental finance restrictions.
The fiscal restraints or otherwise of governments have no bearing on whether or not psychiatry has been pursuing an expansionist agenda. In fact, the psychiatry-pharma alliance has been consistently and successfully pursuing an expansionist agenda for the past 40 years, regardless of the state of the public coffers.
MARGINALIZING THE CRITICS
Sir Simon laments the fact that the media, “fired up” by DSM-5, are “dominated by a radical critique, questioning the legitimacy of psychiatry.”
Note the terms “fired up” and “radical”. Instead of responding in a rational and considered way to our criticisms, he’s attempting to portray us as revolutionary hotheads. And we have the audacity to question the legitimacy of psychiatry! Imagine!
Sir Simon also laments the fact that a UK psychologist used the occasion of the DSM-5 launch to say that all psychiatric diagnosis is wrong, and – listen to this – was not “shouted down,” but was actually allowed to air her views on a radio program! Can you imagine that? Daring to criticize psychiatry! And actually given air time!
COMMANDEERING THE CRITICISM
One of the basic tactics in political spin is commandeer-the-criticism. What’s involved is taking the opponent’s point, accepting it as if it were one’s own idea, but altering it just enough to work to one’s own advantage.
Here’s a nice example that comes near the end of Sir Simon’s article:
“No one can, and no one does, deny that the need to be kind, empathetic and understanding, to see all illness in its social context, to understand all illness as to how it affects the person. Far from being a “radical critique” let alone a mandate for the inevitable “paradigm shift” that our critics are calling for, that is merely a description of good psychiatry.”
The first sentence doesn’t close – but the meaning of the quote is clear: we’re good guys; we’re kind, empathetic, and understanding. We see all illness in its social context and in the effect it has on the person. This isn’t a radical critique. This doesn’t warrant the paradigm shift that these bounders are demanding. This is just good psychiatry.
So all the criticisms which we mental illness deniers direct at psychiatry are just nonsense; just so much wasted effort because … psychiatry is already there! Psychiatry doesn’t need to change!
But notice how the word “illness” got sneaked in twice. And that, as Sir Simon should know, is where the paradigm shift is needed: the recognition that the problems psychiatry is “diagnosing” and drugging are not illnesses. If he has proof to the contrary, this might have been a good place to set it out.
Sir Simon’s final paragraph is a gem of irrelevance. I must quote it in full:
“The reception afforded DSM-5 has reminded us how we sometimes look to the outside world and it is not always pretty. The charge that DSM itself is a Big Pharma fuelled exercise to open new markets for the sale of drugs is not helped when it becomes clear that some of the biggest names in psychiatry have been less than transparent in their financial dealings. Sadly the APA only gives further ammunition to the critics when it charges an exorbitant price for an almost unreadable book of marginal relevance to the mental health challenges facing most of the world. But the public relations disaster could still be turned into a triumph if the APA joined the open access movement sweeping across the world of scientific publishing and agreed to make if not DSM-5, then at least DSM 6, free to all. But I am not holding my breath.”
He mentions the accusation that the DSM is essentially a pharmaceutical instrument to sell more drugs. Now there’s an interesting thought that might have warranted some debate. But no, we move on.
Then he mentions that some of the “biggest names” in psychiatry have been “less than transparent” in their financial dealings. Some of us might have said “corrupt.”
And while we’re on the subject of corruption coupled with big names in psychiatry, let us remember the Sir Simon’s own Institute of Psychiatry honored Charles Nemeroff, MD by inviting him to speak at the opening of their new Centre for Affective Disorders on June 17. In case you’re not familiar with Dr. Nemeroff’s history, here’s an extract from Wikipedia.
“Nemeroff’s undisclosed ties to drugmakers and under-reported incomes from them have raised questions about conflict of interest. Following a Congressional Investigation led by Senator Charles Grassley of the Senate Finance Committee, Nemeroff was found to be in violation of federal and university regulations and resigned as chair of the psychiatry department at Emory University. He was also forbidden by Emory to act as an investigator or co-investigator on National Institutes of Health grants for at least two years. Nemeroff has moved to Florida and become the chair of psychiatry at the University of Miami.
According to the Annals of Neurology, the court documents released as a result of one of the lawsuits against GSK in October 2008 indicated that GSK ‘and/or researchers may have suppressed or obscured suicide risk data during clinical trials’ of paroxetine. ‘Charles Nemeroff, former Chairman of the Department of Psychiatry at Emory University, was the first big name ‘outed’ … In early October, Nemeroff stepped down as department chair amid revelations that he had received over $960,000 from GSK in 2006, yet reported less than $35,000 to the school. Subsequent investigations revealed payments totaling more than $2.5 million from drug companies between 2000 and 2006, yet only a fraction was disclosed’.”
Any reputable profession, I suggest, would have ostracized, and probably disbarred, Dr. Nemeroff. But not psychiatry. In psychiatry, that kind of corruption draws honors and accolades. Sir Simon might have written about that.
He might also have explained to us why his institute hosted a conference to mark the publication of DSM-5 if it is – as he claims – “…a book of marginal relevance…”
Then the insult to end all insults. The APA, Sir Simon writes, has given ammunition to psychiatry’s opponents by over-charging for DSM-5.
Does he seriously imagine that whether DSM-5 costs $10 or $200 makes a nickel’s worth of difference? Does he imagine that if DSM-5 had been less expensive that these protests would not have happened? Is he so out of touch with the fundamental flaws in his chosen profession that he believes that the cost of this book is even on our radar?
And – he tells us – the public relations disaster could have been turned around if the APA had distributed the book free!
And remember, dear readers, Sir Simon is an eminent psychiatrist.