In the lead-in to the 1980 revision of the Diagnostic and Statistical Manual, the field of psychiatry was having a crisis of legitimacy on a number of fronts. The eye of the storm was in the area of reimbursement for services. Psychiatry as a specialty was forced to deal with the issue of legitimacy directly. It was as if the universe had said to psychiatry, "name your illnesses; quantify them; prove their treatments are effective; or perish." The same thing was happening throughout medicine. The medical model of disease at its most concrete is that signs, symptoms, and laboratory studies lead to diagnosis; diagnosis determines treatment; treatments have an outcome. That’s the model for reimbursement purposes. In truth, things are more complicated than that, but the rest of medicine operates with versions of that model and could negotiate with the reimbursement agencies. Psychiatry wasn’t even close, so things had to change. And that change focused on the diagnostic system.<\/div>\n
The American Psychiatric Association had previously published several diagnostic manuals as a service, more code book than anything else. But the APA’s DSM-III took on the new task – it became the vehicle to legitimize psychiatry using the DSM-III to adapt it to the particular medical model of managed care<\/em> that was emerging to handle reimbursement. The American Psychiatric Association moved into the position of defining psychiatry and what psychiatrists legitimately do rather than being a professional organization that represented psychiatrists. In order to do that, the man in charge, Robert Spitzer, allied himself with the element within psychiatry whose vision was the most consistent with medicine proper, the St. Louis Group. They offered him a way to bring off the task at hand, a descriptive atheoretical diagnostic system that could be tested for reliability. The St. Louis Group also had a belief that psychiatry should focus on biology and the biological aspects of mental illness. More or less, that belief came with the descriptive package. While it was bound to have consequences, the DSM-III aimed directly for legitimacy. We "named our illnesses and quantified them" in one blow with "prove treatments effective" to follow.<\/p>\nThe point for the moment is that the American Psychiatric Association took on the role of defining psychiatry, directing its very essence through the diagnostic system and the periodic revisions, and became increasingly allied with the biological side of the equation. And it seems to see itself as the certifying agency for legitimacy. When Dr. Lieberman says, "Without them [our diagnoses], diagnostic approaches could vary widely. The treatment of conditions would be uneven. Payment for services would be difficult, to say the least.<\/em>" Whether he knows it or not, he’s saying that psychiatry’s legitimacy rests in the DSM Manual. It truly is, in the eyes of the APA, the "Psychiatrist’s Bible" as journalists love to name it. Without it, chaos reigns so it must protected at all costs. Without it, we would deteriorate to our primordial state as in the days before the DSM-III – the Dark Ages would return.<\/p>\nI’m overstating that probably, but I’ll hold my point nonetheless. What’s Dr. Lieberman talking about? Nobody’s arguing that we shouldn’t have diagnoses. Dr. Ablow was pointing at something else, "But those labels aren’t driven just by science, but by political, economic and commercial forces within the American Psychiatric Association that may have nothing to do with the well-being of patients – or with reality.<\/em>" He was talking about legitimacy too. He’s saying that just because Dr. Spitzer got us out of a former legitimacy jam with the DSM-III doesn’t canonize the book, and it doesn’t mean it’s not vulnerable to the same kind of special interest forces it was meant to fix. Most people think that it’s being influenced by forces a whole lot less lofty than the ones Dr. Lieberman is talking about. I think that too, and so do you if you’re reading this. Neither he, nor Dr. Oldham, nor Dr. Kupfer, nor Dr. Regier engage specific complaints. They don’t even seem to think they should be challenged. And that last paragraph quoted above sounds as if he expects the Battle Hymn of the Republic to be playing in the background.<\/p>\nIt’s not going to work. Charlie Nemeroff, Martin Keller, Richard Borison, Alan Schatzberg, Sally Laden, Joseph Biederman, TMAP, the Pharmaceutical company’s abetted misadventures, the Speaker’s Bureaus, the sponsored CME, etc. have assured that self-righteousness won’t work. If the APA has taken on the role of shepherd of legitimacy, it’s in an eclipse right now. Every article like Lieberman’s filled with homilies, ignoring the obvious warts, avoiding criticism, harkening to past glories, just complicates things further and digs a deeper hole. That stance just makes him sound like he’s on the wrong side of the legitimacy equation. If he’s not, he’s going to have to prove it…<\/div>\n","protected":false},"excerpt":{"rendered":"
Counter-argument: Changes to DSM-V bring needed improvements FoxNews.com By Dr. Joseph Lieberman May 22, 2012 For decades, the APA has worked diligently to provide definition in the environment of mental health through the development of the Diagnostic and Statistical Manual of Mental Disorders. Since DSM-III, each edition has provided evidence-based guidance in manual form for […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-23715","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/23715","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=23715"}],"version-history":[{"count":17,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/23715\/revisions"}],"predecessor-version":[{"id":23732,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/23715\/revisions\/23732"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=23715"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=23715"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=23715"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
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