Posted on Wednesday 31 July 2013

The DSM-5 has been out for a month and a half and is already old news, if even that. But a few commentaries are beginning to appear with an editorial bent now that the guns have been silenced. Here are a couple of interesting viewpoints from Canada: Ian Hacking, Philosophy of Science, and Edward Shorter, History of Psychiatry:
London Review of Books
by Ian Hacking
8 August 2013

The new edition of the DSM replaces DSM-IV, which appeared in 1994. The DSM is the standard – and standardising – work of reference issued by the American Psychiatric Association, but its influence reaches into every nook and cranny of psychiatry, everywhere. Hence its publication has been greeted by a flurry of discussion, hype and hostility across all media, both traditional and social. Most of it has concerned individual diagnoses and the ways they have changed, or haven’t. To invoke the cliché for the first time in my life, most critics attended to the trees [the kinds of disorder recognised in the manual], but few thought about the wood. I want to talk about the object as a whole – about the wood – and will seldom mention particular diagnoses, except when I need an example….

The DSM is not a representation of the nature or reality of the varieties of mental illness, and this is a far more radical criticism of it than Insel’s claim that the book lacks ‘validity’. I am saying it is founded on a wrong appreciation of the nature of things. It remains a very useful book for other purposes. It is essential to have something like this for the bureaucratic needs of paying for treatment and assessing prevalence. But for those purposes the changes effected from DSM-IV to DSM-5 were not worth the prodigious labour, committee meetings, fierce and sometimes acrimonious debate involved. I have no idea how much the revision cost, but it is not that much help to clinicians, and the changes do not matter much to the bureaucracies. And trying to get it right, in revision after revision, perpetuates the long-standing idea that, in our present state of knowledge, the recognised varieties of mental illness should neatly sort themselves into tidy blocks, in the way that plants and animals do.
Oxford University Press Blog
By Edward Shorter
July 29th, 2013

We’re all suffering from DSM-5 burnout. Nobody really wants to hear anything more about it, so shrill have been the tirades against it, so fuddy-duddy the responses of the psychiatric establishment [“based on the latest science”].

But now the thing’s here, and people have been opening the massive volume — where descriptions of depression are repeated almost verbatim seven times! — and asking what all the shouting was about. Post-DSM-tristesse.

There are a few pluses, and several huge minuses, worth calling attention to, just before everybody goes to sleep again over the question of psychiatric “nosology.” Oh, how the average newspaper reader is turned off by stories on “nosology”.

You have to remember that a lot of smart, well-informed, scientifically up-to-date people were involved in the drafting. So the final result can’t be all horrible…

OK. Now everybody can go back to sleep.
Hacking’s article questions the whole basis of the DSM-5 classification, seeing it as an administrative book without particular clinical value, and little changed from its predecessor. Shorter catalogs the pluses and minuses [mainly the latter]. Both articles are worth a look.

While I agree with Shorter’s observation that there’s an après DSM-5 emotion in the air he refers to as Post-DSM-tristesse [a state of melancholy sadness]. I’m not sure that’s exactly what I feel. Sticking with the French, I might have gone with Post-DSM-ennui [a feeling of listlessness and dissatisfaction arising from a lack of occupation or excitement] – an emotion beautifully captured in Sylvia Plath’s early poem of the same name. The passionate conflicts of the ancient days [1980] when the Psychoanalysts and the Biologists of Saint Louis jousted up and down the halls of the New York Psychiatric Institute were a tired and distant memory. And people seemed to have forgotten the industry that went into the 1994 DSM-IV effort.

Oh there was definitely a fire-in-the-belly when the DSM-5 effort got underway at the turn of the new century. This DSM was to be the one that took psychiatric diagnosis out of the realm of opinion and speculation and finally put it on a long awaited biomedical footing. But as the years wore on, the supporting scientific evidence just didn’t materialize. Worse, the blockbuster psychotropic drugs didn’t wear well with disappointing efficacy and obvious toxicity. But the piece of the story that I think had the most to do with the current apathy was the increasingly frequent reporting of corrupt practices and alliances in the pharmaceutical industry and academic psychiatry – a state of affairs now a part of the general population’s knowledge base.

What Dr. Shorter calls the shrill tirades and fuddy-duddy responses were superficially about the specifics of recommended changes or multiple overlooked areas in need of change, but they were heavily colored by a general disillusionment with the whole enterprise. As strongly as I felt and still feel about the problems with the DSM-5 revisions I wrote about, I’ll have to admit that it’s hard for me to imagine that group doing something that I would have been satisfied with. I was mad about and embarassed by what I saw as the the widespread corruption in the academic·pharmaceutical community. The APA and its DSM-5 Task Force carried on as if it weren’t there, and I think that’s where a lot of the tumult came from.

The Task Force didn’t engage the substantive and fundamental issues. Instead, they played around with idiosyncratic shiny objects. So I don’t feel sadness or melancholy [tristesse]. And during the process, I didn’t feel "that a lot of smart, well-informed, scientifically up-to-date people were involved in the drafting" either. I think I’ll recall the DSM-5 revision period as the time when psychiatry avoided what needed doing – thus my feeling of listlessness and dissatisfaction arising from a lack of occupation or excitement
    August 1, 2013 | 5:25 PM

    Thanks to the Affordable Care Act, many people won’t be denied health insurance due to a DSM diagnosis; but I’d like to know the number of people who have been denied insurance in the past because of one or more mental health labels. Whenever I hear that the diagnoses are made for insurance purposes I get a nagging feeling that the issue of the effects of diagnoses are being swept under the carpet.

    Richard Noll
    August 1, 2013 | 7:16 PM

    FYI — Edward Shorter’s proposal for a new classification and nomenclature:


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