DSM-5: How to Salvage a Shipwreck

DSM-5 was published on May 18, 2013, amidst great criticism.  The fundamental criticism was, and is, that the problems listed in the manual are not illnesses in any ordinary sense of the term.  Other critics focused on the pathologizing of normality, the expansion of the diagnostic net by the lowering of thresholds, and the lack of reliability of the so-called diagnoses.

The response from the psychiatric community has been mixed.  Some, probably most, psychiatrists are keeping their heads down, getting on with the business of selling pills, and hoping that the gravy train won’t derail.  Others are busy at damage control

Jeffrey Lieberman, MD, President of the APA (in a letter to the New York Times) says that:

DSM- 5 “… reflects the current state of our knowledge, limited as it may be. This does not negate its value in helping clinicians evaluate and treat patients, as well as the fact that it can and will continue to be improved as subsequent research enables us to better understand the biology of the brain and mental illness.”

Allen Frances, MD, architect of DSM-IV, is saying that everything was OK when he was at the wheel, but that DSM-5 has just gone too far!

In this context, Joel Paris, MD, has published a book:  The Intelligent Clinician’s Guide to the DSM-5.  I’ve just read it, and it is interesting.  Dr. Paris’ essential position is that DSM-5 is an improvement over DSM-IV, but he concedes that there are problems.  Here are some quotes:

“DSM-III made diagnosis more reliable, but reliability is not validity.  Over the last 33 years, constant use of the DSM manuals has given clinicians the impression that the categories they describe must be valid.  That is not true.  DSM-5 lacks the data to define mental disorders in the way that physicians conceptualize medical illnesses.  Some diagnoses in medicine are also vague, but psychiatry is far behind other specialties in grounding categories in measurements independent of clinical observation.” (pp x-xi)

and

“No biological markers or tests exist for any diagnosis in psychiatry.  For this reason, any claim that DSM-5 is more scientific than its predecessors is little but hype.” (p xi)

and

“It is understandable that psychiatry – so long the Cinderella of medicine – and desperate for respectability, wanted to plant its flag on the terrain of neuroscience.  But the promise of the 1990’s (‘the decade of the brain’) for research on mental disorders has not been fulfilled.” (p xii)

and

[Many patients] “…now receive a 15-minute check-up in which medications are reviewed and ‘adjusted.’  This kind of practice does not allow psychiatrists enough time to find out what is going on in a patient’s life…” p 184)

and

“DSM-5’s ideology supports all these trends.  The practice that follows from a reductionistic view of psychiatry presents itself as a clinical application of neuroscience. In other words, drugs and more drugs.” (p 184)

and

“DSM-5, by expanding the definition of most disorders in the manual, encourages over-treatment.” (p 185)

and

“We are told, without solid evidence, that millions of people with mental symptoms are tragically undertreated.  …The thrust of these arguments…is that drugs should be prescribed to an even larger percentage of the population than is already the case.  The pharmaceutical industry can only rejoice at such conclusions. The rest of us are left to weep.” (p 185)

One can certainly respect and admire Dr. Paris’ honesty.  It is a pity, however, that he hasn’t been voicing these concerns vigorously over the past three or four decades while his colleagues and their pharmaceutical allies were blatantly and confidently promoting the lie that the various problems they were treating were “real illnesses – just like diabetes,” and that psychotropic drugs were real medications which corrected chemical imbalances in the brain and other putative etiologies.

In fairness to Dr. Paris, he hasn’t been a dyed-in-the-wool bio-psychiatrist, but criticizing the excesses of his colleagues after the profession’s venality and invalidities have been outed might justifiably be considered a little late.

In addition, his depiction of psychiatry as “desperate for respectability” is presented almost as a legitimate excuse for the widespread promotion of a spurious philosophy and the destructive “treatments” that this philosophy entailed and legitimized.

All of which leads to the interesting question:  How can Dr. Paris reconcile the very negative things he says about psychiatry with his continued membership of this profession?  How can any psychiatrists continue to practice, when the document which legitimizes their professional activity is acknowledged to be fundamentally and essentially flawed?  Dr. Paris’ approach to this question is two-fold.  Firstly he’s still a believer.

“To address the issue, I hope that bio-markers will eventually be found to make more valid diagnoses.” (p 188)

Secondly he’s distancing himself from DMS:

“For decades, we have treated DSM as if it contained scientific truth, rather than what it really is – a rough draft based on expert consensus.  The manual remains the main guide to psychiatry for medical students and residents.  But its mechanical approach to diagnosis and treatment is not appropriate for sophisticated medical specialists.  Psychiatry has a richer diagnostic tradition that should trump constructs that are little but political compromises.” (p 187)

To which I can only respond that if psychiatry does indeed have “a richer diagnostic tradition” than that which is embodied in DSM, then they’ve been keeping it well hidden for the past 30-40 years.

But having said all that, I do believe that Dr. Paris is to be commended for his honesty.  He says that DSM is rubbish, and it is.

We need to keep in mind, however, that DSM is not the central issue.  The central issue is the spurious medicalization of all problematic behaviors and emotions.  The DSM is just the visible symbol.  We should definitely be glad to see the manual going down in flames, but we should remember that the bigger problem still confronts us.  Even Dr. Paris, one of psychiatry’s more outspoken critics of DSM, still clings to the medicalization myth.  And although DSM is being consigned to the trash cans, psychiatrists world-wide are still selling pills with unabated zeal and enthusiasm.  At this time, antidepressants are the second most prescribed class of drugs in America: second only to antibiotics!

 

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