1 Boring Old Man

^{"For that matter, DSM is not even a diagnostic manual. Its command of diagnostic process is weak. And it certainly has never been a scientific document. Since the days of Gerald Klerman as Administrator of ADAMHA leading up to DSM-III it has been clear DSM is mainly an administrative manual. It was not designed for actually making diagnoses. It is designed to ensure that the diagnoses made by clinicians conform to a minimum symptomatic data set for reimbursement purposes. All other claims are just hand waving and humbug."}

It didn’t take very long to figure out that the DSM-III was much more. The first part was easy. It was anti-psychoanalysis and anti-psychotherapy and since that’s what I came into psychiatry to learn about, my orientation was a kiss of death and I exited stage left quickly. It’s hard to convey what that was like back then, because there’s been so much change. In my mind, psychiatry and the various psychologies of mind were in no way a dichotomy. There were the ‘diseases’ of psychiatry – Schizophrenia, Manic-Depressive illness, Melancholia, etc. that I thought of in the same medical way I’d thought of physical diseases as an Internist. And there were psychological causes of mental illness that were ‘dis-eases’ of the mind – the thing I’d come to learn more about. I was as interested in one as the other, in fact, would’ve not even made that distinction at the time any more than I would distinguish medical diseases of structure [coronary artery disease] from metabolic diseases [diabetes mellitus]. But found myself in a world where that kind of approach was no longer possible. And it all hinged on the DSM-III, which turned out to be a regulations manual rather than a look-up book.

It was a paradigm shift, sure enough. The shift, as I understood it, was to a purely descriptive, evidence-based diagnostic system. I was used to that from Internal Medicine. Many areas had formalized diagnosis in that way: Rheumatology, Cardiology, Diabetes. Criteria lists that were followed rather rigidly. I had found the clarifying. They had been carefully taped into my "ectopic brain" [those bulging little black books training physicians carry around for reference] – another kind of look-up book. But the shift was more than that. The DSM gradually came to be a Diagnostic Manual – meaning a How To book, essential for making the diagnosis – more textbook or rule book than a coding look-up book. It defined Diseases [Disorders]. All kinds of things were keyed to it: reimbursement, disability, FDA Approval, Clinical Trials and other research, medication approval, actually everything. And that just happened. I don’t recall a vote, or a declaration on that point. I just remember seeing that it occurred in an epidemic or a tsunami fashion parallel to the regulatory changes in all of medicine that came with Medicare, Medicaid, and Managed Care. It became our Diagnosis Regulations Book, and the DSM-IIIR, DSM-IV, and DSM-IVTR continued the tradition.

1. A Treatment Manual:
   Which seems to me to be an extension of the Algorithm Movement that lead to the Tri-University Guidelines, TMAP, STAR*D, IMPACT, TORDIA, TADS, CO-MED, EMBARC, etc. The idea is that Diagnosis [eg MDD, Bipolar, Schizophrenia] is welded onto a specific treatment sequence or pathway. When the DSM-5 Task Force speaks, they usually include treatment in the rationale for a diagnosis.
   ^{"If patients are suffering not from normal sadness or grief, but are suffering from a severity of symptoms that constitute clinical depression, and need intervention, and they want help, that they should not be prevented from getting the appropriate care that they need because somebody tells them that, well, this is what everybody has when they have a loss."}
2. The Biological Basis of Mental Illness:
   While it was obvious that the most vocal supporters of the DSM revisions were psychiatrists who were primarily interested in psychopharmacology and matters biologic, they stuck to the descriptive moniker in the earlier revisions. From the start, this one has been different, beginning with Dr. Kupfer’s book laying out a blueprint for the DSM-5. They envisioned lab tests and biomarkers that would define diagnosis precisely as in the rest of Medicine. Even though those things didn’t materialize, the trajectory is little altered. Dr. Insel’s Psychiatry as Clinical Neuroscience is just around the corner. They even propose including the biology part in the definition of mental illness:
   ^{"A behavioral or psychological syndrome that reflects an underlying psychobiological dysfunction."}
   And the biological/medical bias is barely under the surface in what they say publicly:
   ^{"Darrel Regier, the psychiatric group’s research director, characterized critics as being unconvinced medical treatment is better than counseling."}
3. Public Health and Preventive Medicine:
   This part is everywhere. We used to treat the patients that came to us, but now there’s a background that almost feels like ‘trolling for patients.’ But in the DSM-5 Proposals, nowhere is it more obvious than in the Attenuated Psychosis Syndrome where the implication is that we should preemptively treat people who ‘might’ develop a mental illness.