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.