The story of how my wife and I ended up on a Mediterranean Cruise in our early thirties on a ship filled with British "Holidaymakers" would take up several pages, but have nothing to do with why I mention it. The trip started in Split Yugoslavia in the days of Marshall Tito, and stopped in various places in that country before moving on to the Grecian Isles and Athens. We spent several days in Dubrovnik, a treasure of a walled city on the Adriatic. It was our first trip to a certified communist country, and if that was communism, I was all for it – great food and wine, a spectacular ancient city full of friendly animated people [who would barter and trade for anything, any time]. The Yugoslavians were little different from the Greeks or other Mediterranean people I met on other travels. I had no clue that there was no such entity as Yugoslavia, that it was really an amalgam, that the seemingly uniform culture of people were waiting for Tito’s communism to die so they could get back to the business of ancient ethnic wars and would be slitting each others throats in the not too distant future. We thought we were in a real place, but it was an illusion created in the aftermath of the World Wars – one that exploded as quickly as it was formed when circumstances allowed. We watched the destruction of Dubrovnik twenty years later on television in stunned disbelief.
The story of why I was reminded about that trip is as convoluted as the one that explains why I was there in the first place, or how I ended up on a french web site last night called stop-dsm.org. But once in a new place, there are often unexpected treasures. It’s the fun of traveling, even on the Internet. I recently mentioned that I was an anglophile, but I’m a closet francophile too. I love reading Sartre, Camus, Foucault, Derida, Lacan. I can rarely tell you clearly what they said later, but in the reading, I am captivated, and I do remember the music even if the lyrics fade away. Like my trip to Yugoslavia, it’s something of a magical mystery tour.
HAVING IT OUT ONCE AND FOR ALL WITH THE DSM
The Mandatory Diagnostic Reference to the DSM is contrary to scientific initiative; Harmful to treatments of the human psyche; Costly for governments; Paralyzing for research and teaching.
The term “psychical or mental suffering” cannot be confined to the traditional definition of “illnesses,” because it may impact anyone and everyone. The World Health Organization has deemed it a major priority, but then initially engaged itself in the struggle against it via a one-sided choice which views the Manual issued by the APA (American Psychiatric Association) as grounded in science. WHO’s restrictive choice bears the generic name of “DSM,” or Diagnostic and Statistical Manual of Mental Disorders, the third version of which stigmatizes conflicts that are important to psychiatric evaluation, and is contemporaneous with the treatment recommendations of the behavioralists and practitioners of CBT. Since its methods are not clearly delineated, they are also contributing to the promotion of an indispensable pharmacological accompaniment…
So maybe now I can explain why I thought of that trip to Yugoslavia in my late youth. I saw something artificial but I didn’t know it. It was a false unity forged for reasons of historical necessity and maintained by force. It contained the roots of failed monarchies, ethnic and religious hatred, the early 20th century conflicts between fascism and communism – all unresolved for more than a generation until they could later see the light of day. Reading the stop-DSM Manifest, I felt the same way. The authors weren’t afraid to be psychoanalysts or psychologists. They scoffed at phrases like "evidence-based" as a trick. They openly pointed to the hegemony of the Cognitive Behaviorists and the Psychopharmacologists in the DSMs. It reminded me of the heated debates we had in the 1970s [and all enjoyed]. And while it felt very french, it also seemed very real.
I personally loved the eclecticism of psychiatry when I arrived in the early 1970s from the world of Internal Medicine and hard science. I could and did read Freud, Kernberg, Beck, Kraepelin, Bleuler, Psychopharmacology Texts, Carroll’s Dexamethazone Suppression Test, Bateson, Bowlby, Ellis, Liang, etc. and learned something from each without having to resolve the unresolvable. In the morning I was a crisis intervener in the ER, then on to the wards where I was a biological psychiatrist. In the afternoon I was a psychodynamic psychotherapist with my outpatients, and that evening I ran a group and thought about Bion, help-rejecting complainers, and scapegoating. Early on, it was like there were a universe of ways to think, and my task was to find the one that fit the circumstance. Later, it became disconnected from its outside roots and became just the way I thought, my toolbox, constantly modified by cases and the new things I read. I got smarter and dumber at the same time, and it was just my cup of tea. The coming of the DSM-III and its revolution changed the world I lived in, but I’ll admit that it had no real impact on my thinking about people. I understood its political and fiscal roots, but it was clinically immaterial. And though I learned the nuts and bolts to take my boards and talk to trainees, I didn’t buy the book and I never thought about it in my decades of practice when I was in the room with an actual patient.
I’m now retired and pretty well versed in the DSM history, but that’s latter-day learning. I acquired used copies of the DSM II, III, IIIR, and IV that I bought and read as part of writing this blog. I get why it happened, what it was intended to be, what it became. I can explain and calculate kappa. I think Dr. Spitzer and Frances did some amazing things and have included them both in my pantheon of thinkers. But I still see patients and I can’t actually recall the DSM explicitly coming to mind when I’m in the clinic, even now. It’s an academic exercise for me, created to write this blog about the perversion of science in modern psychiatry, but the DSMs themselves are experience-distant from my doctor self. That’s just the way it is and always has been. I have lots of old friends who are Social Workers, Psychologists, Pastoral Counsellers, Biological Psychiatrists, etc. and have some new ones made in the course of writing this blog. I respect them all as clinicians and I think it goes the other way. I remain a part of the psychoanalytic community, but am hardly the cardboard Freudian I read about. The mind brain dichotomy lives in my head. I still go for bio-psycho-social as a model. I’m a decent Neurologist when the need arises. I’m sure I’m a different clinician than I was in 1980, but the DSM had no part that I know of in that. I write this paragraph in celebration of feeling somewhat liberated by this reading to be the mental health mongrel I really am.
A methodology with zero clinical validity
The DSM’s repertories of “disorders” and “dysfunctions” only furnish psychical or mental suffering with surface level clichés. There is no branch of medicine in which a practitioner would diagnose an illness founded solely on the manifest expression of a symptom. Since information provided by regular patterns (invariances) are avoided on principle, surface descriptions are multiplied: this so-called “Evidence Based Medicine,” which claims to favor evidence in pursuit of greater effectiveness, reveals its true goal by limiting clinical explorations to the most superficial evidence, and by mixing up elements of otherwise heterogeneous orders (particularly the clinical and moral): take for example the comment by Dr. Roger Misès about “behavioral problems, “ which he refers to as “incivility” cum illness.
The result is an inflation of “disorders,” an inflation which corroborates the aforementioned absence of scientificity, since an authentic scientific initiative enables us to delimit a large variety of manifestations to a few clinical types whose number has been reduced. From the 106 pathologies listed in the version from 1952, the DSM’s current version now identifies 410 “disorders.” DSM-V, which is currently being developed, should log at least twenty-some additional categories. In terms of mental pathology, it has constructed various “false positives” whose sole beneficiaries would appear to be the pharmaceutical companies. What is more, this inflation is nurturing the birth of catchall concepts that justify sometimes dangerous and stigmatizing treatments for children.
In prior versions of the DSM, a clinical category as constant as hysteria, witnessed to by the experience of Antiquity even, was deleted. In similar fashion, neurosis has no longer been included since 1980, although homosexuality would have to wait until 1987 to no longer be viewed as a mental illness; the date when, paradoxically enough, sexuality itself lost its status…All this leaves us with the idea that these statistics refer more to American culture, its norms and its fashions, even as the DSM’s psychopathological categories reveal their international ambitions. Indeed the WHO plans to impose the application of the ICD on a global scale within the next few years.
As for the planned DSM-V of the future, new and entirely dimensional categories are being invented, based on the amplitude of the manifestations it deems pathological, such as “hypersexuality disorder” and “coercive paraphilia disorder.” Even more troubling still, the addition of “predictive factors” as portents of “future disorders.” Each of us will thus potentially be ill and thus candidates for preventative treatment. The pinnacle of this vertigo-inducing inflation is no doubt reached with the invention of “risk syndromes” such as “psychotic risk syndrome,” which goes from prevention to prediction by calling for the systematic prescription of psychotropic medications at non-negligible doses for adolescents who are deemed atypical. And all this despite the fact that no field test has even shown its usefulness. Such an expansion of pathology might even be deemed against Human Rights.