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Phillip Elias | Tuesday, 23 March 2010

Crazy controversy

A psychiatrist told me once that some people are born mad (eg, his wife’s relatives), others achieve madness, and others have madness thrust upon them by the Diagnostic and Statistical Manual (DSM).

Earlier this year American Psychiatric Association released its draft version of the fifth edition of DSM, DSM-5. The controversy raging around this publication, previously fuelled by its alleged secrecy, radicalness, and lack of organisation, was now fanned by the proposal of significant changes to various diagnoses. Critics, led by editors of previous DSMs, have expressed their concern that new disorders and the loosening of criteria in old ones will greatly increase the number of false positive diagnoses and generate a host of negative consequences.

The DSM was first published in 1952 and evolved from US military classifications of mental disturbances. It listed 106 diagnoses. The first two editions were slim (less than 150 pages) and heavily influenced by psychoanalytical concepts of mental illness. DSM-III, published in 1980, represented a paradigm shift. Assumptions about the underlying causes of disorders were abandoned in favour of a classification system based on clusters of symptoms. Mental illness became categorical (that is, present or not present based on finding a certain number of symptoms) rather than dimensional (that is, more or less present in an individual based on psychological experiences and one’s adaptation to them). Some argue that while early editions of DSM were merely a guide to psychiatric diagnoses, DSM-III and subsequent revisions took on a much more authoritative guise. It became the psychiatrist’s Bible.  It certainly weighed as much as a Bible, being 494 pages long with 265 diagnoses. DSM-IV continued in the same vein and added a great deal of empirical data.

The changes in DSM-5

The task force in charge of DSM-5, apart from dropping the Roman numeral in the acronym, has proposed a number of significant changes for the manual. At the diagnostic level, these include the addition of subclinical or pre-morbid conditions (such as “psychosis risk syndrome”) as disorders, a reclassification of the personality disorders, and the addition of an assortment of new diagnoses such as gambling addiction. At a more global level, the editors have proposed adding severity assessments to many diagnoses, purportedly making the manual more dimensional in its approach.

A simmering conflict over the publication has erupted over the past months. It would be impossible to detail here the interests of the parties involved or the specifics of the points of disagreement. As mentioned, editors of earlier editions are particularly concerned that new diagnoses and the loosening of existing criteria will create many more “false positive” diagnoses, that is, patients being labelled with a mental disorder where none is present. The risks for individuals include stigma, a reduced sense of responsibility, unnecessary exposure to potentially dangerous medications, and difficulties getting life insurance. Society may become increasingly medicalised and resources may be misallocated. At a philosophical level, there are implications for human freedom.

Defenders of DSM-5 deny this, saying that the changes are not that radical. This may be the case. But the problem of false positives in psychiatry remains. It predates the current controversy and could reflect not a problem with DSM-5 but with DSM and psychiatry itself.

Psychiatry’s identity crisis

YOUTUBE_VIDEO_MIDDLEMost non-psychiatric medical practitioners (including myself) recognise the unique position of psychiatry in the medical profession. Psychiatrists have an incredibly large and complex patient population. Little is known about the cause of most of the disorders they treat. They have not a single diagnostic test at their disposal. Their most comprehensive and definitive manual continues to expand its base and extend its reach and is constantly undergoing substantial revisions. A member of one of the DSM-V Work Groups recently resigned over this point, stating “I am not aware of any other branch of medicine that does anything like this.”  

The DSM debacle resurrects the question as to whether psychiatry should be considered solely as a “branch of medicine”. Psychiatrists seem to want this. Much of the definitiveness of DSM III and IV and their purported reliance on clinical trials, along with their claim to be “atheoretical”, reflect a profession which is desperate to identify with and emulate the success of other fields of medicine. But psychiatry loses a lot from this approach. Being definitive, or categorical, may be useful for the purposes of statistics and clinical trials, but it belies the observable fact that psychiatric symptoms are complex beasts of continuous, rather than discreet, nature. Clinical trials are essential but they cannot be the only source of knowledge about mental illness. I was told once that an actually practicing psychiatrist also needs a good deal of “Verstehen” (I had to look up the meaning of the German word). Such knowledge is acquired from experience and from exposure to literature, history and philosophy.

That psychiatry is atheoretical is hardly a boast. It is akin to being proud of the fact that one’s car has no engine. It may be green but it doesn’t take you very far. Psychiatry needs some sort of account of fundamental causes beyond what biology reveals and I don’t think this will change. Without a theoretical framework or a delineation of normal  human psychology there is no limit what could potentially be considered pathological. Clinical studies will find new symptoms, new categories, and new permutations of the two.  More diagnoses will be made, and more pharmaceuticals will be sold.

Psychiatry is not like the rest of medicine. Its aspiration to become so has, rather than shedding light on mental disorders and simplifying their diagnosis, greatly complicated the matter. It has contributed an epidemic of false positive psychiatric diagnoses. Whether DSM-5 will have anything significant to say in this regard remains to be seen.

Phil Elias is a Sydney doctor.

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