i used to be more sympathetic to criticisms of DSM-V, but a couple of months back i went to see a psychiatrist. who told me he didn't believe in it. fair enough. but he then diagnosed me with something and prescribed me a drug. when i asked why, he said i should trust his intuition. without DSM-V or anything similar there was no structure - nothing i could understand or question. no logic. just "intuition".
maybe i am missing the point. i can see that "labels" are annoying. but surely there has to be some systematic approach to symptoms...
[edit: got psychiatry and psychology swapped...]
Psychologists are well aware that, for instance, "schizophrenia" (and I'm not going to check whether that's still in the DSM V, if not the point here holds) is probably more than one thing, and as soon as they work out the details, they will be given multiple names. In the meantime, so that everyone is on the same page, it has a description as clear as possible (which is not always very clear).
The DSM is intended to be descriptive, not prescriptive, and not exhaustive. It is also not intended to be casually perused by people who don't understand the purpose, because of the high probability of suffering Medical Student's Disease [1] as a result.
[1]: http://en.wikipedia.org/wiki/Medical_students%27_disease
I don't think the DSM-V protects against the problem you observed when seeing a psych, either. I saw one a while back who did believe in the DSM-IV (V wasn't out at the time) and his approach was still 'it sounds like you fit the clinical definition of this; I can prescribe you this medication'. The diagnostic process was, ultimately, 'if this medication helps you probably have this condition'. I think it's reasonable for that to unnerve you, but that's really just a symptom of how difficult it is to actually draw concrete, verifiable conclusions about this stuff.
Many of the conditions described in a tome like the DSM-V as a singular condition end up having wildly varied symptoms and there end up being treatments that only work for one subset of people with the condition, while another treatment only works for another subset. Some people who have a condition only show a tiny subset of the symptoms. I think it's reasonable to look at that and ask if some well-meaning people have gone overboard in an attempt to label and categorize everything.
On a related note, there are many marginalized groups out there that feel victimized by the authors of tomes like the DSM, because it often classifies things as 'disorders' that ought not necessarily be a disorder. Those with unusual sexual orientations, gender identities, or social habits are among the people who at one time or another have been considered mentally deficient or mentally ill due to classification. I don't think the people authoring those classifications necessarily intended to harm those marginalized groups, but that often IS the result.
And from what I have experience with--the eating disorder community--many professionals actually discredit the DSM's categorization (though it has much improved in the DSM-5) because of its insistence on weight for diagnoses of anorexia nervosa. But great American insurance often will pay for nothing if the patient does not have either AN or BN leading to patients being "not sick enough" for treatment when really, they need it as soon as possible for recovery to be most successful.
(i got a second opinion from someone who spent much more time talking with me, understanding what was happening, and discussing possibilities. he used DSM-V as a framework that allowed him to structure things. that was all. he was awesome and i was happy with his decision. and that's because he was a good doctor, not because of DSM-V. but as a good doctor, he wasn't discarding a useful tool for "religious reasons")
[edit: all the above is necessarily simplified; i now feel a bit guilty in portraying the first doctor so negatively. there's clearly factors like client-doctor "fit" involved, too.]
A "weak interpretation" of the DSM where it's a collection of clustered symptoms, together with some advice about what treatments appear to have worked or not worked in the past for them, wouldn't really run into that. But some people do seem to have a stronger interpretation where the manual acquires a normative/definitional component, in which it's supposed to define the line between "mentally ill" and "normal psyche". Then you get into a huge amount of uncertainty that we still have over the etiology of any of these conditions, plus political battles over what counts as normal in the first place, the long fight over whether homosexuality should be included being probably the most famous example. Occasionally legal status can even be tied to being diagnosed as "mentally ill", which is where it starts coming closest to the dystopian-novel feel, although that may be the fault of legislators more than psychiatrists.
I guess the part of this article that's most explicitly a critique is this:
> DSM-5 seems to have no definition of happiness other than the absence of suffering.
...but that only really applies to certain ways of using the DSM, the weak pragmatic one not being among them, since it would recognize that treating acute suffering is only a small component of human psychology in the more general sense.
So now we have the situation where an unelected, private body (the American Psychiatric Association) wields immense power over people's daily lives.
This is the problem the author is alluding to in this passage:
> On some level we’re to imagine that the American Psychiatric Association is a body with real powers, that the “Diagnostic and Statistical Manual” is something that might actually be used, and that its caricature of our inner lives could have serious consequences. Sections like those on the personality disorders offer a terrifying glimpse of a futuristic system of repression, one in which deviance isn’t furiously stamped out like it is in Orwell’s unsubtle Oceania, but pathologized instead.
You do realize that one of the biggest criticisms of the DSM-5 is that the inter-rater reliability for many diagnoses is no better than a coin flip, right?
the problem is that, at least in my case, DSM-V was replaced with an appeal to authority.
when the alternative is "ok boss, you know best" i prefer a list of symptoms where i can argue, "look, almost anyone could tick half these boxes at some point in their lives". at least i can see what's happening.
i am not saying that DSM-V is a rule book that should be followed blindly. i am not saying that it is "right", or that it carries some kind of moral weight. all that i am saying is that any communication - even dissent - needs a common vocabulary, and DSM-V can provide that.
from my outside perspective it seems that it's a tool; that the real problem is some of the doctors. discarding the tool won't improve the bad doctors, it will just make them less accountable. how is that an improvement?
The simplest example that comes to mind is hysteria. We can easily see how this well discussed ‘ailment’ was actually an undercurrent of misogyny and class warfare.
This goes hand in hand with the various forms of dysfunctional medicalization over the years. From Lombroso to the medicalization of the woman, the African American, the Jewish Race, etc.
There appears much more at stake than benevolent labelling.
DSM or no, too many doctors prescribe medication off-label. People with one of the personality disorders get a diagnosis and then some semi-random medication with some experimental[1] psychotherapy. All the clinicians disagree about what the treatment should be, but they see that as a feature of the patient's illness. Thus, if the patient is doing exactly what Dr A wants (but not what Dr B wants) Dr B will say it's the patient's manipulation which is part of the illness, and not that it's just a conflict among the team
I'm not sure how it works in the US, but some psychiatric diagnoses can be used to detain a person in hospital against their will. There's no court process, no judge. There are some protections, but these are not great.
The downside is that the old system of involuntary commitment, which I do believe civil-liberties campaigners were right to campaign against, has not really been replaced with anything. Some proportion of those who were previously involuntarily committed are better off, living some kind of life, whether a normal one, or some kind of bohemian one, or with family, or otherwise getting by. But some proportion are a mixture of homeless and in and out of jail or 72-hour holds, without any serious long-term attempt to do anything about their situation. Especially true if either they lack close family, or lack family with enough means to take them in, or have psychotic episodes that their family finds threatening. A schizophrenic guy I know through the tech scene is in that category; has been 72-hour held 4 or 5 times, on a 2-week hold once, arrested for various kinds of minor disturbances a dozen times, etc., but never received much treatment, except during the short periods of psychiatric confinement.
I did a 6-week rotation in a psych ward for exclusively psychotic patients ( mostly schizophrenic, some manic). I can't recall if they were all held specifically for being a danger to themselves / others, but remember court orders being regularly obtained (and always required) and then only for patients who were very psychotic (medically psychotic --> delusional, typically to the point of being unable to function).
> DSM-5 seems to have no definition of happiness other than the absence of suffering. The normal individual in this book is tranquilized and bovine-eyed, mutely accepting everything in a sometimes painful world without ever feeling much in the way of anything about it.
Positive psychology[1] is a branch of psychology that agrees with this critique, and rather than looking at what goes wrong with people, it looks at what is right about people. There is a book "Character Strengths and Virtues"[2] that is aimed at being the positive counterpart to the DSM, providing a taxonomy of character strengths that have been identified across different times and cultures.
1. http://en.wikipedia.org/wiki/Positive_psychology
2. http://en.wikipedia.org/wiki/Character_Strengths_and_Virtues
Let's suppose that you feelings are summed up by a score, happiness is just score 0 and normality being between 0 and a very small negative interval; also suppose that you cannot go over zero and everything that can happen can either:
- decrease that score (you feel bad about something, and that feeling is related to a certain, possibly temporary, disorder);
- increase that score, but only up to them maximum value of zero (you feel bad, but that friend helped you and her jokes are actually funny).
It may be that positive traits and strengths do exists, but it is also possible that they are limited to being able to only putting you back on track once you have a problem, not making you more happy or "normal" that you can possibly be.
But this begs the question [1] of whether it's the person or the job that's "at fault" or "abnormal". That's where some of the criticism originates: one allegation is that perfectly normal people are being diagnosed as mentally ill and told they need treatment, when they are maladapted to a job that in fact most humans are maladapted to. In other words, they are within the normal range of human behavior, but treated as mentally ill because their job expects abnormal human behavior.
[1] In the precise meaning of the term.
1. "DSM-5 seems to have no definition of happiness other than the absence of suffering. The normal individual in this book is tranquilized and bovine-eyed..."
The DSM does turn mental disease into an entirely negative subject: you're mentally healthy only if you lack any of the listed disorders. The name "Diagnostic and Statistical Manual" does limit the enterprise contained within, but practically speaking, the DSM is the Bible for mental health professionals. It's the document that describes a substantial portion of how to give care to the mentally sick, and no other document has the same stature.
And yet their Bible contains nothing at all about mental hygiene or positive practices. Consider how odd that is, how it distorts the mental health professions. In the realm of "physical" health, medical doctors speak with unanimity on every medium imaginable about how you should exercise regularly, eat more fruits and vegetables, etc., to stave off cancer, diabetes, heart disease, and an array of other ailments. How often do you hear psychiatrists talk about the importance of working on your empathy and forgiveness skills? N.B.: doing so will make you happier.
Again, cataloguing symptoms is important, but not all-important. DSM sucks all the air out of the room and leads those who study the mind to focus excessively on the neat categorization of symptoms rather than means of staving off mental illness in the first place or of developing admirable virtues like courage, self-discipline, and justice.
2. "On some level we’re to imagine that the American Psychiatric Association is a body with real powers, that the Diagnostic and Statistical Manual is something that might actually be used, and that its caricature of our inner lives could have serious consequences."
We know that the caricatures have serious consequences for millions of people, which ought to horrify us. I've seen the consequences of this kind of over-pathologization up close. I've had several criminal clients who've been seriously affected by faulty prison diagnoses of schizophrenia and bipolar disorder. These faulty diagnoses led to the prescription of the powerfully soporific antipsychotic Risperdal, which turned my clients into physically weak zombies, and, for that reason, into victims of sexual assault. Admittedly this is an extreme example, but it amply demonstrates the power of the DSM.
Their "paranoia" may have had something to do with: a. being watched 24 hours a day, b. being chased around by some sociopathic fellow inmates, c. being subject to the rule of arbitrary and capricious guards, or perhaps some combination of the 3.
Also, from the prison's perspective, prison is not a nice place, and psychiatric labels and medications are useful for keeping inmates in line.
I should note that blacks in the general population are disproportionately diagnosed with schizophrenia, and it's probably from overdiagnosis due to race-based misunderstandings. Check out http://www.medscape.com/viewarticle/768391 and this study http://archpsyc.jamanetwork.com/article.aspx?articleid=11510..., which confirms on a small scale what I've seen anecdotally in the prison context
Some people have problems that some type of professional help can enable them to solve. This can range from people who need medication to avoid seeing and hearing things that aren't there to people who need CBT to get out of a self-destructive rut to people who need cosmetic surgery to feel like their body fits their subjective gender. But the United States is full of systems where you need a diagnosis to do anything--bill insurance, prescribe medication, declare someone to have a disability so they can collect income without working. So DSM is a tool for psychologists and psychiatrists to put a code down on a form so the system will let them help people.
This is why there's a stipulation that it's only a mental illness if it prevents you from living a normal life. Lots of people have the symptoms of mental illness, just not to such a degree that it warrants intervention. Having compulsive rituals is perfectly normal--compulsively washing your hands until they bleed is not. A good mental health professional will know the difference and only provide a diagnosis when it's necessary. But ultimately the DSM isn't a bedrock of abnormal psychology, it's just a tool psychologists use to make the system let them help people.
That sounds about right.
As someone who mostly appreciated the DSM-IV (though recognized its shortcomings), this is my biggest concern with the DSM-V, and why I consider it to be a step backwards in many ways.
CAVEAT: My understanding of the DSM-V is based on earlier drafts/non-final editions, so some of these details may be stale, but it appears the general principles that I object to haven't changed.
The DSM-IV-TR was very specific with its definitions of "substance abuse" and "substance dependence". My main complaint with the former was the way two of the criteria were poorly worded. It referred to the amount of legal trouble and/or risk that the person took to obtain the drug and could, if very broadly (mis-)interpreted, be used to identify any user of any illegal drug as suffering from "substance abuse" just by definition[0]. This is mostly a quibble about the wording of one detail, though; I think that these were good definitions overall and were more helpful than not.
Criticially, the DSM-IV-TR was able to distinguish between casual users of a drug (be it caffeine, alcohol, marijuana, heroin, etc.) and those who actually suffered from "addition" (a term I put in scare quotes because it does not have a medical definition, unlike the words "abuse" and "dependence").
This is a crucial distinction. If you send someone who drinks infrequently but is not an alcoholic to rehab, you are providing treatment for a disorder that they do not have. Thus, you wouldn't be surprised (or concerned) to find their behavior unchanged six months later. You would not consider it a "relapse" if they continued to drink infrequently.
Unfortunately, the DSM-V turns this on its head, by allowing "fill-in-the-blank" intoxication disorders. Think of generic classes in Java - they work the same way. Given the name of any drug, you can provide the corresponding disorder - in this case, "caffeine intoxication disorder", or "marijuana abuse syndrome"[1]
The problem with the new wording is that it encourages over-diagnosis of mental disorders. Instead of requiring a professional to distinguish between disorders and non-disorders (easy), it lumps all together as disorders, and requires professionals to distinguish between those which require treatment and those which don't (hard).
This is not only more difficult medically, but more problematic legally. No doctor or hospital wants to accept the liability of saying that they saw a patient previously diagnosed with a disorder and then determined that they didn't need treatment. This is far worse than simply failing to diagnose a disorder.
This may seem like a minor point, but it's not. We've been struggling with issues of overdiagnosis and overtreatment of non-disorders (not just drug-related) for years; in a very subtle way, the DSM-V further entrenches this problem.
[0] Incidentally, DSM-V did drop the "legal trouble" criterion.
[1] I forget the exact wording of the latter; this was a while ago and I believe they changed it.
Don't most of them include wording similar to "... and causes problems in the patient's day to day life" after a list of diagnostic criteria?
Thus, Bob drinks 15 cups of coffee per day, and it doesn't bother him doesn't suffer from CID, but Ann who drinks 12 cups of coffee per day, and suffers significantly if she cannot get coffee (or is perhaps routinely overdosing on caffeine) does suffer from CID?
It was removed in about 1975. There's plenty of dumb stuff done in many areas of science 40 years ago.
In this the DSM-V is another brilliant piece of fictional writing. A world where everything is classified, pathologised, and detached from its context, values, society, and causes. During the entire tome, you are completely separated from any notion of wellness, love, morality, or healthy human beings, with everything classified and filed away like a work-bench with little boxes for every possible failing.
It finally hits you as you feel so disgusted and alienated by the conclusion of the novel...that this is specifically because the narrator is so alienated and separated from such realities, and the novel has succeeded perfectly in its goal. To put you in such a tortured, flawed, and erroneous mindset that you now understand completely the flawed and erroneous mindset and worldview of the narrator.
Kudos to the author. Another masterpiece.
http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20t...
Very interesting additions/clarifications.
Even the guys on the inside don't trust it.
http://mindhacks.com/2013/05/03/national-institute-of-mental...
For instance, https://en.wikipedia.org/wiki/Sluggishly_progressing_schizop...
Or as Richard Feynman coined it: Cargo Cult Science http://en.wikipedia.org/wiki/Cargo_cult_science
Also lets not forget these same people claimed being homosexual was a mental disorder until 1973!
Basis of knowledge disclaimer: I am not a medical doctor, and I have never attended even an undergraduate-level course in psychology. On the other hand, I have been reading extensively about psychology for twenty years,[1] mostly focusing on research on human intelligence and human behavior genetics, and over the years my participation in online discussion networks gained me an invitation to participate in the "journal club" (graduate seminar course) on human behavior genetics at my alma mater. At the behavior genetics seminar, I have met several researchers who have been trying to clean up psychiatric nosology and improve the newly released edition of DSM. The researchers I know locally do NOT like the framework or approach of DSM-5. I'll try to do a layman's justice to their point of view in what I write below.
We have discussed before here on HN the blog of the director of the National Institutes of Mental Health, which included a post "Transforming Diagnosis,"[2] casting considerable doubt on the diagnostic approach taken in DSM-5, which was published just before DSM-5 itself was published. Most researchers agree that to develop better understanding of troubles patients experience, and better approaches to treatment, a lot of mental disorders will have to be recategorized (including no longer being categorized as disorders) based on new criteria. That's what the progress of science will look like in this field.
It's important to remember that Freudianism was still in vogue when I was young (and constituted most of the higher education in psychology that my parents received in the early 1950s) and psychology and especially psychiatry are STILL undoing some of the harm caused to those disciplines by mistaken ideas from Sigmund Freud. It's easy to tell persuasive stories about what makes people's minds work, but much harder to test those stories with evidence.
Neurologists who are interested in science-based improvement of medical practice have commented[3] on DSM-5, and comments of that kind point the way forward to improvement of nosology in psychiatry in the future. Therapists may have to give up their pet "specialities" to recognize the realities of how to help patients. There will surely still have to be new diagnostic tests and new drug treatments developed. The DSM-5 didn't do as well as it ought to have to advance understanding of mental disorders. But its evident faults will prompt further research, and DSM-5 will eventually be replaced by a new edition, one I hope will be based on better science.
[1] https://en.wikipedia.org/wiki/User:WeijiBaikeBianji/Intellig...
[2] http://www.nimh.nih.gov/about/director/2013/transforming-dia...
[3] http://www.sciencebasedmedicine.org/dsm-5-and-the-fight-for-...
Sounds about right. (http://imgur.com/a/IJnR2)
