BACKGROUND
On 19 April, The Conversation ran an article titled Mental disorders: debunking some myths of the DSM-5, by Perminder Sachdev, MD. Dr. Sachdev is a psychiatrist, and was a member of the DSM-5’s Neurocognitive Disorders Work Group. He works at the School of Psychiatry, University of New South Wales, Australia. (Thanks to Dave Traxson on Twitter for the link.)
ANALYSIS
Let’s start with the title. “…debunking some myths of the DSM-5.” This sounds good. You might get the impression that he’s going to address the myth of mental illness – the myth that all human problems are illnesses and are best treated by drugs. But – alas – you would be mistaken. Dr. Sachdev lists four myths that he plans to debunk. He refers to these as the “…four key criticisms about DSM-5…” Let’s examine what he says about these one by one.
1. It’s impossible to classify mental disorders
This, remember, is one of the “key criticisms” that is leveled against DSM-5. I think it would be fair to say that I’m reasonably familiar with the criticisms that are being directed against the DSM, but I don’t think I’ve ever heard this one. I have heard numerous critics express the criticism that the concept of mental disorder has no validity, or explanatory value, and is not a helpful way to conceptualize human problems. But I’ve never heard anyone say that these putative entities can’t be classified. Indeed, for most of us on this side of the argument, saying that mental disorders can’t be classified would invalidate our central position, in that we would be acknowledging the ontological reality of these purely fictitious psychiatric inventions. How can you classify something that doesn’t exist in the first place?
People have problems. That is not in dispute, but the notion that these problems stem from, or are best explained as manifestations of, mental disorders is nonsensical and destructive. Moreover, it is probably the issue on which the anti-DSM movement is most united. It is the central criticism.
It would have been honest and interesting if Dr. Sachdev had made this his first myth:
There are no mental disorders/illnesses.
He might have marshaled some ideas, and we could have had some serious debate. Instead, he does what we’ve been seeing a lot of lately – the old psychiatric side shuffle: don’t address the issue; address something tangential. Politicians have been doing this for years.
Imagine if the scientists at CERN had been asked: “Well, did you find the Higgs boson?” And they replied, “We have some really nice quarks to show you.”
Incidentally, you’ll find exactly the same side shuffle in DSM-IV (1994). On page xvi you’ll find this gem: “The need for a classification of mental disorders has been clear throughout the history of medicine, but there has been little agreement on which disorders should be included, and the optimal method for their organization.” Here again, we glide right over the much more critical question: has the concept of mental disorder any validity in itself? – and go straight to the problem of classifying these fictitious entities. Classifying mental disorders, incidentally, is on a par with classifying witches!
Anyway – back to Dr. Sachdev.
“The primary purpose of the DSM-5 is to enable physicians and other clinicians to reliably diagnose patients who present with a mental disorder.”
Note the word “reliably.” DSM-5’s own field trials showed unequivocally that the manual is extremely unreliable. Different psychiatrists routinely assign different diagnoses to clients presenting the same problems
Dr. Sachdev must be aware of the results of the field trials, and so he might reasonably have been expected to point out that DSM-5 is a failure with regard to what he describes as its “primary purpose.” Again, there’s a similarity to politics: Say something often enough and people start to believe it.
Dr. Sachdev acknowledges that some diagnostic discrepancies can occur, but he assures us: “…using the DSM, two clinicians working remotely from each other should reach the same diagnosis for a particular patient.”
Maybe he doesn’t know about the field trials? Maybe be doesn’t care? Maybe it’s just spin.
2. The DSM is just a money maker
Certainly some critics have commented on the financial aspect, but it’s never been a major part of the anti-DSM movement.
But note how Dr. Sachdev deals with this.
“Considering that about US$25 million has already been spent on the fifth revision process, as estimated by the chair of the task force, it does not appear to be a great investment if book royalties were the primary objective.”
He tells us what the APA has spent, but doesn’t tell us what the projected income is. Fortunately, however, Dan Gorenstein of Marketplace Health Desk has done a cost revenue analysis, How much is the DSM-5 worth? Here’s a quote:
“And he [Dr. James Scully, CEO of APA] says with 150,000 pre-orders the DSM-5 is a hot seller. ‘We may do a second printing more quickly than we originally thought,’ says Scully. At $199 dollars for the hardcover, $149 for paperback — that’s more than $20 million in sales right there.”
Actually at paperback price, it’s nearly $22.4 million. So assuming that they sell even a modest number of hard cover copies, they have recouped their initial investment already. And remember, up till last week, DSM-IV was still bringing in $4-5 million a year. So projecting a 20-year lifetime, the DSM-5 will likely prove very profitable.
So let’s go back to Dr. Sachdev. He tells us that he’s going to debunk the myth that the “…DSM is just a money maker.” Then he tells us that $25 million has been spent, but says nothing about projected earnings. There are three possibilities. Either:
1. He’s not very bright.
2. He’s being deliberately deceptive.
3. He thinks we’re not very bright. Does he imagine that we will say something like: “Oh, gosh, $25 million. That’s such a lot of money. Thanks, Dr. Sachdev, for debunking the cash cow myth!”
And this guy was a member of the DSM-5 Neurocognitive Disorders Work Group. So he must be really bright, right?
3. Under the DSM-5, more people will be diagnosed with a mental disorder
Here it gets even worse:
“The process of revising the DSM is extremely rigorous, and any proposal for a new disorder or a major revision of existing criteria needs to come on the back of strong scientific evidence.”
The twin pillars of scientific evidence are reliability and validity. The APA’s own reliability figures for DSM-5 were embarrassingly dismal, and Dr. Thomas Insel of NIMH stated publicly on April 29 that the diagnoses had no validity whatsoever; a statement, incidentally, he has not recanted despite some suggestions to the contrary.
From Dr. Sachdev:
“Any new proposal must be accepted by other members of the advisory group, all of whom are experts in their field.”
There it is: we’re experts, we’re doctors; you can trust us.
Now he debunks the proliferation-of-diagnoses myth – brace yourself.
“…the total number of disorders will not be more than in the DSM-IV: 297.”
I hate to repeat myself, but here again, he demonstrates that either: he’s not very bright; he’s being deliberately deceptive; or he thinks we’re not very bright
A ten-year-old child could tell you that there are two broad ways to catch more people in the “diagnostic” maw:
1. Invent more “diagnoses.”
2. Lower the threshold on existing “diagnoses.”
So to tell us that the total number of diagnoses will be the same doesn’t debunk the “myth.” One of the major criticisms directed at DSM-5 over the past year has been the lowering of the thresholds. Could it be that Dr. Sachdev is not aware of this?
He then goes on to talk in general terms about thresholds, but seems blithely unaware of the fact that this is the central issue in the “myth” that he has not debunked.
4. The DSM is trying to redefine what’s normal
This is a complicated issue. It is my contention that the behaviors and feelings cataloged in the DSM are, for the most part, normal reactions on the part of individuals to abnormal situations. They emphatically are not illnesses or manifestations of illnesses residing in the individual. In a very small number of cases there may be some neural malfunction, but in the vast majority of cases the behaviors and feelings can best be understood in well-established psycho-social terms, and to assume a neural pathology in every case is unwarranted and dangerous.
So by calling all these loosely clustered syndromes mental disorders/illnesses, the APA is indeed pathologizing normality and doing so to an increasing extent with each edition of the DSM. And this is not to say that the behaviors/feelings in question are not unusual or troublesome or even downright devastating. They can be, and frequently are. But they’re not illnesses!
Dr. Sachdev clearly believes that this last paragraph that I’ve written is a myth. And if he wants to debunk this myth, all he has to do is adduce clear and convincing evidence that all of the troublesome behaviors/feelings listed in the DSM are caused by physiological pathology. At which point I will fold my tent, retract what I’ve written, apologize profusely to all concerned, and go back to my vegetable garden.
But up until now all I’ve seen from psychiatry in this regard is a long string of discredited theories.
And from Dr. Sachdev, we don’t even get a theory – just more patronizingly pathetic spin.
“The DSM-5, and any other classification of mental disorders, is not an attempt to define what is normal. Being normal is not the same as “not having a DSM-5 diagnosis”, and having such a diagnosis is not the same as being “insane”, as some have wrongly argued about the DSM.”
And that’s it. The “myth” is debunked because Dr. Sachdev says so! So with that “myth” out of the way, Dr. Sachdev treats us to a couple of gems of irrelevancy:
“Many individuals, including physicians, find it difficult to accept that mental illness…is common…”
“The DSM-5 must simply be regarded as psychiatry’s next faltering step. It’s not above criticism, but is probably the best manual of mental disorders that we are likely to have for some time.”
I’m sorry that this is so lengthy, but it is so offensive to see these people using this kind of self-serving drivel to justify and bolster their spurious, destructive, and disempowering practices, while dismissing and discounting the cries of their victims.