1 Boring Old Man

DSM-5: A Manual Run Amok
^{It’s time for psychiatry to drop its field guide and try to learn about mental ills}
Wall Street Journal
By PAUL MCHUGH
May 17, 2013

… With its third edition [DSM-III], the manual [which had existed since 1952] underwent a transformation. Its editors focused on codifying symptoms that seemed to distinguish one mental disorder from another. If psychiatrists would use these criteria consistently, they suggested, then perhaps researchers would be able to explain and differentiate disorders in terms of psychobiology. This prescription for diagnostic peacemaking radically changed the psychiatric scene. No longer was it an unruly market of claims, counterclaims and "orientations." Psychiatric practices became centered on using the manual to identify disorders, much as a naturalist uses a field guide to identify birds or trees. The treatments derived from these diagnoses had no particular theory behind them. They were efforts, mostly pharmacological and rule-of-thumb, to provide relief from symptoms. Psychiatric thinking about patients and their disorders withered.

Today the public complains that psychiatrists seem ready to call every state of mental distress an illness. They see that any restless boy can receive a diagnosis of attention deficit disorder, that troubled veterans—whether exposed to combat or not—are routinely said to suffer from post-traumatic stress disorder, and that enormous numbers of discouraged, demoralized people are labeled victims of depression and have medications pressed upon them. The public is not far wrong. A recent nationwide diagnostic census based on DSM claimed that the majority of Americans have or have had a mental disorder. As a result, an appalling number of young adults in schools and colleges are on one form or another of psychiatric medication.

The problem, though, is not only that psychiatrists have gone too far in naming mental states — they surely have — but that they have gone on too long with their field-guide checklists. They seem unable to do better. DSM-5 will be more of the same — a way to "know of" disorders without "knowing about" them, to draw a distinction made by William James. With its new manual, the APA might instead have started taking steps toward a system of classification that, as in medicine, organizes disorders according to what we know about their natures and causes. Such knowledge, rather than checklists of symptoms, would then direct treatment and research.

Psychiatrists know, for instance, that depression and anxiety can derive from a number of different sources: cerebral diseases such as schizophrenia and bipolar disorder; alcoholism or drug addiction; experiences of loss, deprivation or trauma; and, more generally, a vulnerable temperament, characterized by introversion, shyness and emotional intensity. Deciding which of these sources, alone or in combination, applies to a particular patient requires hours of evaluation. Prescribing an appropriate treatment involves not checking symptoms but determining who the patient is and what he or she has experienced and done.

DSM-5 displays none of this thinking. It remains a field guide organized by symptoms, clustered in categories that can expand without limit. Official, APA-approved psychiatry seems to lack the will to change. It justifies its stagnation not only by reminding its members of the chaos of the 1970s but by claiming that the U.S. health system would not pay psychiatrists if they tried to know their patients the way that they could and should.

DSM-5 is a missed opportunity to advance the discipline, instruct the public and encourage financial support for needed psychiatric services. Its editors seem willing to waste another decade before dispersing the mysteries of psychiatry and bringing practitioners and patients together in understanding what they are doing and why.

This WSJ article starts with a critique of the version of psychoanalysis that dominated psychiatry in the pre-1980 days and why things needed to change. In spite of being an analyst myself, most of what he had to say are things I generally agree with, but I thought Dr. McHugh’s description of the post-1980 state of play was exceptional [above]. While critical, he’s fleshed out the essential elements in a clear and concise  way and points to a rational alternative.

^{DSM-5 is a missed opportunity to advance the discipline, instruct the public and encourage financial support for needed psychiatric services. Its editors seem willing to waste another decade before dispersing the mysteries of psychiatry and bringing practitioners and patients together in understanding what they are doing and why.}