Have the DSM committee shot themselves in the foot?

Because it sets the crucial boundary between normality and mental illness, DSM has gained a huge societal significance and determines all sorts of important things that have an enormous impact on people’s lives—like who is considered well and who is sick; what treatment is offered; who pays for it; who gets disability benefits; who is eligible for mental health, school, vocational, and other services; who gets to be hired for a job, can adopt a child, or pilot a plane, or qualifies for life insurance; whether a murderer is a criminal or a mental patient; what should be the damages awarded in lawsuits; and much, much more. – Allen Frances

Last Wednesday the American Psychiatric Association released the fifth edition of its Diagnostic and Statistical Manual (DSM-V).

I wonder if they expected the reaction they’ve been getting.

The past week has seen an unprecedented spate of negative articles in the mainstream media, with attacks on the manual from both flanks.

The Asperger’s Syndrome community is outraged that their classification has been abolished by rolling it into the autism spectrum.

Some Aspies (and I use the term fondly – I qualified for it myself under DSM-IV) are upset about being lumped in with far more seriously disabled autistic people and many others are worried that the tightened diagnostic criteria will take away the label they have become accustomed to wearing. (It is estimated that 10-30% of those currently classified as having Asperger’s Syndrome will fail to meet the diagnostic criteria for autism spectrum disorder.)

This is not just a question of self identity or identification with the broader community of Aspies (important though that may be), in many cases it will mean reduced access to the services that came with the label and, potentially, reduced tolerance for our geeky quirks in the workplace or classroom.

But the greatest outcry is not coming from those worried about tighter diagnostic criteria, but those concerned about the opposite – diagnostic inflation.

In 1952 the first edition of the DSM listed barely over one hundred mental illnesses and disorders. DSM-V defines well over three hundred. It seems craziness has been growing by leaps and bounds.

Dr Allen Frances headed the panel that compiled DSM-V’s predecessor, the DSM-IV. He has since recanted many of his earlier views and considers much of his work on the manual to have been a mistake.

He believes DSM-V to be an even worse mistake than DSM-IV, taking us yet further down the path of classifying normal, if unpleasant, human experiences as mental illness.

And he knows who to blame.

“The history of psychiatry is the history of fad diagnoses. Fashion plays a large part. And fashion is now being very much influenced by the drug companies,” says Dr Frances, “The drug companies are enormously powerful and it’s my belief that they should not be allowed to market at all. We stopped big tobacco’s influence by preventing its advertising. I think we should be doing the same thing with the pharmaceutical industry.”

I urge everyone who is interested in the diagnosis and treatment of mental illness to read Dr Frances’ interview with Emma Alberici on Lateline. In a two minute dialog he puts his finger precisely on much of what is wrong with contemporary psychiatry.

But some mental health professionals are even more critical than Allen Frances.

Dr Thomas Insel, director of the US National Institute of Mental Health, has denounced DSM criteria as invalid, not based on any objective measures and nothing more than constructs put together by committees of experts.

As America’s most prominent psychiatrist, Dr Insel has labelled psychiatry a pseudoscience. And he is not alone.

Last week the British Psychological Society called for a paradigm shift in how mental health is understood, dismissing the biomedical model of mental illness and calling for a return to the emphasis on social and personal factors in the understanding and treatment of psychological distress. They insist that there is no validity to diagnostic labels such as schizophrenia and bipolar disorder.

It seems that in a single week I have been cured of both Asperger’s Syndrome and bipolar disorder via the simple virtue of abolishing their definitions. I feel better already.

The sudden rush of skepticism in conventional psychiatric diagnosis prompted by DSM-V has opened space for alternative perspectives beyond the social and personal, with the notion that at least some psychiatric conditions are cultural constructs also regaining currency.

But none of this is new.

The critical views expressed above would have been considered completely mainstream in 1960s psychiatry. Disciples of RD Laing, David Cooper, Michel Foucault and Thomas Szasz would have gone much further.

Even by the 1970s when I was studying psychology and neurology (or ‘physiological psychiatry’ as it was then called, as it incorporated the endocrine system as well as the nervous system) textbooks gave equal space to physical, experiential, social, cultural and even spiritual causes of mental disturbance.

It has only been since the the 1980s that the billions of dollars pouring into drug company coffers from ‘blockbuster’ psychiatric medications have been able to fund the full spectrum dominance of psychiatric discussion needed to push all potential rivals of biopsychiatry into the shadowy margins of mental healthcare.

It is probably worth noting that the first wave of psychiatric medication, the phenothiazine antipsychotics such as thorazine, were not initially seen as therapies at all but as ‘major tranquilisers’ designed to keep asylum inmates quiet and manageable.

That is why they are still often referred to as ‘chemical straitjackets’ or ‘liquid cosh’.

It was only increased concern for the human rights of the mentally ill during the late 1950s and 60s that prompted the development of the dopamine D2 pathway theory of psychotic illness, which was retrofitted to existing drugs so that they could be portrayed as therapies rather than restraints.

Yes, antipsychotics do suppress the positive symptoms of psychosis. That’s because they suppress just about all mental activity. A lobotomy does the same thing. In fact, by interfering with or destroying the D2 dopamine pathways antipsychotics are actually a form of titrated lobotomy. But with extra side effects such as weight gain and diabetes on top of the extrapyramidal effects they share with botched psychosurgery.

We can hope that the hubris informing the drafting of DSM-V has dealt a body blow to the overwhelming dominance of biopsychiatry but the drug companies have deep pockets and overwhelming influence over most GPs and psychiatrists.

The label hangers and pill pushers may be down, but they certainly aren’t out.

But perhaps we are seeing the first steps away from the diagnostic dead end that has hobbled mental health research and treatment for half a century.

Some day psychiatry may even be fit to be called a science.