1 Boring Old Man

Counter-argument:
Changes to DSM-V bring needed improvements
FoxNews.com
By Dr. Joseph Lieberman
May 22, 2012

^{For decades, the APA has worked diligently to provide definition in the environment of mental health through the development of the Diagnostic and Statistical Manual of Mental Disorders. Since DSM-III, each edition has provided evidence-based guidance in manual form for use by clinicians and researchers to diagnose and classify mental disorders so that patients in need can be effectively evaluated and gain access to treatments.}

^{The definition of mental illnesses may at times be a matter of debate – and they should be. But the importance of mental illness and the need to recognize and diagnose it cannot be understated.  Without them, diagnostic approaches could vary widely.  The treatment of conditions would be uneven.  Payment for services would be difficult, to say the least.}

^{However, through biomedical research and enhancement of public awareness we have made great strides in the U.S. to establish a strong scientific basis for our understanding of human behavior and brain disorders that affect mental functions and bring them out of the shadows so that people can recognize symptoms and seek treatment.}

The American Psychiatric Association had previously published several diagnostic manuals as a service, more code book than anything  else. But the APA’s DSM-III took on the new task – it became the vehicle to legitimize psychiatry using the DSM-III to adapt it to the particular medical model of managed care that was emerging to handle reimbursement. The American Psychiatric Association moved into the position of defining psychiatry and what psychiatrists legitimately do rather than being a professional organization that represented psychiatrists. In order to do that, the man in charge, Robert Spitzer, allied himself with the element within psychiatry whose vision was the most consistent with medicine proper, the St. Louis Group. They offered him a way to bring off the task at hand, a descriptive atheoretical diagnostic system that could be tested for reliability. The St. Louis Group also had a belief that psychiatry should focus on biology and the biological aspects of mental illness. More or less, that belief came with the descriptive package. While it was bound to have consequences, the DSM-III aimed directly for legitimacy. We "named our illnesses and quantified them" in one blow with "prove treatments effective" to follow.

The point for the moment is that the American Psychiatric Association took on the role of defining psychiatry, directing its very essence through the diagnostic system and the periodic revisions, and became increasingly allied with the biological side of the equation. And it seems to see itself as the certifying agency for legitimacy. When Dr. Lieberman says, "Without them [our diagnoses], diagnostic approaches could vary widely.  The treatment of conditions would be uneven.  Payment for services would be difficult, to say the least." Whether he knows it or not, he’s saying that psychiatry’s legitimacy rests in the DSM Manual. It truly is, in the eyes of the APA, the "Psychiatrist’s Bible" as journalists love to name it. Without it, chaos reigns so it must protected at all costs. Without it, we would deteriorate to our primordial state as in the days before the DSM-III – the Dark Ages would return.

I’m overstating that probably, but I’ll hold my point nonetheless. What’s Dr. Lieberman talking about? Nobody’s arguing that we shouldn’t have diagnoses. Dr. Ablow was pointing at something else, "But those labels aren’t driven just by science, but by political, economic and commercial forces within the American Psychiatric Association that may have nothing to do with the well-being of patients – or with reality." He was talking about legitimacy too. He’s saying that just because Dr. Spitzer got us out of a former legitimacy jam with the DSM-III doesn’t canonize the book, and it doesn’t mean it’s not vulnerable to the same kind of special interest forces it was meant to fix. Most people think that it’s being influenced by forces a whole lot less lofty than the ones Dr. Lieberman is talking about. I think that too, and so do you if you’re reading this. Neither he, nor Dr. Oldham, nor Dr. Kupfer, nor Dr. Regier engage specific complaints. They don’t even seem to think they should be challenged. And that last paragraph quoted above sounds as if he expects the Battle Hymn of the Republic to be playing in the background.