I’ve been thinking about the DSM-5 a lot more than I’d like lately, but in the process I’ve at least clarified a few points in my own mind – strewn about below in no particular order:
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The worst thing is something that didn’t actually make it into the manual, but I’ve talked about it ad nauseum here. They actually set out to create a diagnostic manual that was organized along biological/neuroscience lines – even though they didn’t have direct evidence to support such a move. They wanted to use the power of the APA and the DSM’s place in mental health to put forward a theory of mental illness that is speculative and self-serving to a specific group. That was exactly the wrong that Dr. Spitzer’s DSM-III was designed to set right. They spent a few million have conferences/symposiums to collect justifying evidence, and it wasn’t there to be collected. From my point of view, this was the negative legacy from Dr. Spitzer, Dr. Sabshin, and the Saint Louis group’s power grab in 1980 – the tradition that a select group in the APA defined the psychiatry in specific and mental health care in general. I attribute the closed shop nature of their deliberations to be part of this tradition, something like the "Invisible College" of the DSM-III years. They couldn’t bring it off, but the fact that they tried so hard discolors the whole process in my estimation. It was an agenda driven enterprise that has the biological momentum in the spaces between the words. When they had to admit that they had no solid basis to go bio, there was a campaign from every corner assuring us that it would soon be with us. This is not a revision. It is a failed attempt to force a paradigm shift by changing the manual, just like their predecessors in 1980 had done. And from my vantage, that’s all it is.
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The justification for many of the changes they did make had to do with making sure patients got treated – removing the bereavement exclusion being the prime example but there are plenty of others. Who’s to say that the American Psychiatric Association is tasked to tell us who to treat and who not to treat, or even how to treat. They’ve already bludgeoned us enough with their treatment guidelines. Again, it’s more Big Brother stuff – a function that I don’t recall being in the APA charter. Their guidelines and treatment oriented diagnostic changes are uniformly way too trigger happy with the current biological agents available – and they make mincemeat out of their claims to be conflict-of-interest free.
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Twenty-five years ago, using expert opinion was understandable. But here on the fourth iteration, it’s ludicrous to claim to be an evidence-based specialty and still be relying on experts most of whom are academics doing biological research with heavy pharmaceutical ties, whether they’ve been suspended for the duration of the task force or not. They had 13 symposiums on ways to go bio but not on the diagnosis of clinical syndromes. And their recurrent proclamations with the expert-counts fall on dead ears.
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The lack of deference shown to our colleagues in other mental health specialties was a blatant insult to all concerned. The only group who thinks mental illness is a big brain thing are the people on the DSM-5 Task Force and their friends. The overwhelming majority of mental health practitioners who use the manual don’t think mental illness is all biological and couldn’t do anything about it if they did. If they didn’t feel insulted, they should have.
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There are areas in the DSM-III, III-R, IV like MDD and GAD that are just plain wrong that weren’t even touched. Any fool who sees a patient with Melancholia knows that it’s not a sibling, not even a cousin, of the patient who comes to an office or volunteers for a Clinical Trial saying, "I’m depressed." "The blues" and "the black dog" are different species. Just ask them.
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I am a medical physician who came into psychiatry belatedly, after my medical identity was consolidated. As a medical physician, I’m embarrassed when the so-called scientists on this Task Force talk. The don’t sound "medical" – they sound like wanna-bes. We have some real scientists in our midst, but I don’t hear them beating the drum for the DSM-5. My guess is that they’re embarrassed just like I am.
So it’s not just the details on the DSM-5 that I oppose. It’s the whole gestalt, the culture and process that created it. It’s the hubris of the APA to condone and protect this kind of arrogant pseudo-expertise. I don’t know if a solidified boycott movement will come together. I kind of hope so because the DSM-5 is not something people should be using. But in the long run, this is going to be a black day in the history of psychiatry, adding to our problems rather than helping us solve them. I feel most concerned about the legitimate biological researchers because this is going to leave a very bad taste that will linger long. That brings me to my last complaint:
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The DSM-5 Revision was an opportunity to right a lot of wrongs. The DSM-III, for all its foibles, did do that. This Task Force didn’t. If I can make an forced analogy, it’s like what would’ve happened if instead of Dr. Spitzer, they had turned the DSM-III Revision over to a committee from the American Psychoanalytic Association. While a little more representation from that group might have been a good idea, it sure wasn’t a time to give them the reins. This DSM-5 Task Force was composed of and run by the very people that needed the reforming – and that’s my biggest complaint. We all knew that was true all along, but only a few brave souls said anything. This was a missed opportunity of mammoth proportions…
Do. Not. Buy. It.
imagine if sales were less than 50% as expected by the APA? Don’t think they can imagine that. Don’t think or act like a captive audience.
I really think we can make the APA irrelevant. It will take time, energy, and maybe a little money besides what you’d overpay for that destruction of trees the APA has ordered.
just my opinion. And goal.
Oh, this will be received as a harsh analogy, but look at the DSM5 as the APA’s Mein Kampf. After all, it is an outline for what to do with society.
I know, I know, I am stretching credibility here with this comment…
A little Godwin now and then won’t spoil the Reich. I think you’re going in the right direction and that goes along with what I wanted to add— the class issue of how the DSM is applied based on ability to pay, the type of insurance a person has, and the ability of people who know the client to speak for them (if they’re not also poor and without a lawyer). The consequences of a diagnosis are much worse for someone whose bill is being paid publicly, it could follow them everywhere, and is more likely to be used to force treatment against the poor and working poor don’t have much in the way of advocacy available to them. And people who are being controlled by a spouse or family member(s) can find themselves in horror watching mental health professionals collude with their abusers to keep them in line.
I have no doubt that I spent two weeks in lock-down because I would not agree with the psychiatrists’ diagnosis or treatment. and because the Veteran’s Administration would pay the bill. I was not a threat to myself or anyone else. I was floridly psychotic for about two hours. I needed sleep. The married woman with the child at home who she cared for 24/7 staged a suicide attempt and was out in a day and a half.
MEDICAID/MEDICARE/V.A. FRAUD.
I think the real issue is that most psychiatrists are either too busy or are disillusioned with medical journals and do not read them. There are so few voices because few people have the time or the expertise to organize a voice.
Physicians need an actual website, perhaps advertised to them by mail or email, word of mouth, etc, where they can go and fill out a simple form to join an organized protest. Lending a voice is easier then being a lone voice.
It doesn’t sound so hard in principle, legal expertise can be paid for. One thing can be for certain, although this was a missed opportunity of great proportions to raise a voice, the opportunity will only increase as the manual fails to live up to expectations. Criticism has only been growing over the years, and there is a tremendous reservoir of emotion not properly tapped into by any professional group.
The failure to organize is the most intriguing part, everything is basically there.
… the whole gestalt, the culture, the process of creating DSM-5, the hubris of APA… condoning and protecting… this mammoth exercise of pseudoexpertise…
Thank you, dr Nardo, for nailing the totalitarianism of the APA undertaking so clearly on the wall, for all to see the politics of who stand to gain and who are to be slaves continually drugged and exploited under the guise of modern versions of drapetomania, child bipolar, opposition, hyperactive etc, most often gifted, energetic children, entirely normal, entirely misdefined by guardians of limited empathy and understanding and quacks doing the bidding of the evil system. The barrel is rotten, rotting the apples that did not wake up in time, until the Reich must be crushed by outside forces.
I did not understand Wiley’s Godwin reference, but by googling I found Godwin’s law. As the quack science of racial biology was the rationale leading to the Nazi killings of persons, groups and whole peoples defined – by doctors, psychiatrists, biologists, lawyers and politicians – as unfit to live and propagate in the fantasy Aryan Empire of the Nazis’, I find it wholly appropriate that warnings are pointing to inherent dangers for the largest minority on Earth of the axis powers of APA-Big Pharma-National governments. These lessons of history are vital for the survival of all that we say we hold dear
Looking back on this era from the perspective of historians of the future, I have a question:
Is there an equivalent historical/critical literature regarding the internal decision-making process and evaluation of scientific evidence for the psychiatric disorders in the International Classification of Diseases? Wouldn’t that be the default system if, as so many critics seem to wish, DSM was deemed too flawed to be fixed by a flawed APA political process and therefore be abolished?
I am sympathetic to the criticisms of the APA, DSM, and the Moloch of managed care in the US that demands such categories from psychiatry if it is to be regarded as a legitimate branch of medicine. (This of course begs the question as to whether psychiatry is, or ever was, a legitimate branch of medicine) But in books, blog posts and media accounts I have yet to find a comprehensive counter-proposal for a meaningful alternative.
ICD seems to be the only alternative at present. All of the criticisms of DSM regarding reliability, validity and pressure from special interests outside the medical profession could easily be turned on the WHO and its ICD.
I say: be careful what you wish for. Comprehensive counter-proposals are necessary, not just critiques and complaints.
If someone knows of a comprehensive counter-proposal, or a historical/critical literature on the ICD process regarding psychiatric conditions, I would be grateful if someone could direct me to those sources.
Richard,
Excellent points. The short answer is I don’t know the answers, but have the same questions. The resident resource on this issue is Suzy Chapman of dxrevisionwatch who is encyclopedic on this topic. I’ll get to this topic myself at some point, but in the interim, I’d peruse her site.
Thanks,
Mickey,
Thank you. I don’t want to give the impression I am unsympathetic to the critiques (heck, I agree with just about everything you write and greatly appreciate the way in which you express yourself — more autobiographical reflections are always welcome, as I am a refugee from that DSM-III transitional era).
I will check out Chapman’s site.
Richard
Richard Noll, I would like, most respectfully, to point in the direction of international human rights and the continually accumulating documentation collected by survivors of psychiatric abuse in many parts of the world, culminating in the UN CRPD treatey, ratification of which was recently voted down by the US Congress. But the challenge is alive, see http://www.chrusp.org
Berit BJ, thank you. I was unaware of this organization.
Speck,
You make a good point.
But would physicians and researchers not be asked to ally themselves with those implicitly (and explicitly) linking them as a whole to the Nazis and Dr. Mengele and his ilk? This site is run by a psychiatrist and there are multiple Nazi analogies being made in the comments section of this page alone. Few clinicians and researchers are going to question the right of an individual to be outraged at what happened to their loved one. At the same time I can’t see how people in those fields are going to join in when their identity is simply vilified.
What seems to set Dr. Goldacre’s campaign apart is that he is not saying that the bulk of those who work in these fields are evil or terribly misguided. He’s certainly not making direct comparisons to death camps. He is putting forward a message that has at least some chance of garnering support from a large number of individuals within the fields and corporations themselves.
One challenge is that there is a lot of money to be gained for those supporting the DSM-5 but not much money to be gained for those opposing it. A possible exception being in the changes in the autism category and that is where there has probably been the most effective counter-campaigns have been mounted.
For better or for worse, appropriately classifying more people as bereaved isn’t going to make people a lot more money. So it’s hard to generate the same motivation. Sadly.