Making the DSM-5: Concepts and ControversiesRichard Balon, MD
Wayne State University, Detroit, Michigan, USA
Edited by Joel Paris and James Phillips. New York, NY: Springer; 2013; ISBN 978-1461465034; pp 180; $39.95 (paperback).
Everybody who reads what I call psychiatry’s tabloids (eg, Psychiatric News, Psychiatric Times, Clinical Psychiatry News)—and even those who do not—may have witnessed or been a part of the intense debate over DSM-5. At times, the intensity of the debate, involvement, and even personal attacks were quite surprising. Especially, as the authors of 1 of the treatises in this small volume, Owen Whooley and Allan Horwitz, write, “Taking a step back from psychiatry’s interpersonal squabbling, the rage that surrounds the DSM revision process seems strange. After all, it is only a medical taxonomy. Other taxonomies, like the International Classification of Diseases (ICD), hardly register in the popular conscious. They certainly do not warrant front-page stories in The New York Times. No other professional organization dedicates as much energy and resources into their classificatory systems as the APA [American Psychiatric Association]. … Taxonomies are typically mundane and unobtrusive parts of modern life, rarely noticed, much less fought over vehemently in the pages of the popular press. The DSM is a great exception to this rule” (p 76). So, why are there such intense debates, fights, numerous articles, and even books—such as Making the DSM-5—over “just a taxonomy?” The reasons are complex and multiple, with the foremost being “a case in which the identity and authority psychiatry hinges—or at least internally seems to hinge—on how it structures its taxonomy” (p 76). Other “ingredients” include the intellectual crisis of psychiatry as a discipline, intellectual crisis and lack of meaningful results of all neuroscience research, politics, financial aspects, possible conflicts of interests, numerous “stakeholders,” and, as in many debates, personalities of the debaters. Perfect storm?
As a partial attempt to address some controversies, Joel Paris and James Phillips put together this small, multi-authored volume. It is divided into 3 parts (Historical/Ideological Perspectives; Ideological and Conceptual Perspectives; and Conceptual Perspectives) and contains 11 chapters (actually, only 10, as the last chapter summarizes the previous 10 chapters). In the first chapter, Edward Shorter, a well-known historian of psychiatry, summarizes “The history of DSM.” He emphasizes that there are 3 approaches to creating a nosology, “reliance on authority, on consensus, or, the third, by identifying a disease by the ‘medical model,’ a well-defined process that depends on more than ‘consensus in opinion or symptoms alone’” (p 4). In discussing the DSM-III, Shorter summarizes all those for whom the DSM-III complicated things, including the pharmaceutical industry—”On the one hand, the DSM-III diagnoses were a gift, handing industry ‘diseases’ on a plate for which they could indicate agents that previously had only such vague labels as ‘anxiety.’ On the other hand, the FDA would insist henceforth that industry use DSM-III diagnoses in drug development” (p 13). He adds “This was a Danaean gift, a poisoned chalice, as industry would soon learn in trying to discover and develop drugs for such heterogeneous indications as ‘major depression’” (p 13). At the end of his entertaining chapter Shorter states that “The DSM series is more a cultural than a scientific document” (p 13). In the following chapter, “Considering the economy of DSM alternatives,” John Z. Sadler focuses mainly on what he calls “the mental health-medical-industrial complex” (MHMIC), a term derived from the “medical industrial complex” originally coined by Arnold Relman in 1980, editor of the New England Journal of Medicine at the time. Sadler suggests that there are 10 elements of the MHMIC: 1) millions of mentally ill people; 2) pharmaceutical industry; 3) for-profit service industry; 4) US healthcare system; 5) US politics; 6) advertising and mass media; 7) the National Institute of Mental Health (NIMH); 8) popular demand; 9) academic medical centers; and 10) the APA. Dr. Sadler’s premise regarding the DSM dominance in diagnosis/nosology is simple: “The DSM has prevailed because it has, on balance, served its function in the MHMIC, whose monolithic influences on funding, public policy, and the social discourse on mental illness reinforces the DSM’s stability and success” (p 24).
The witty chapter 3 titled, “The ideology behind DSM-5,” by Joel Paris, starts with the statement that “An ideology provides a comprehensive vision.” (As I grew up under the Communist ideology, I would add that ideology could be—and is frequently—blind, misleading and dangerous.) Yet, Paris adds, “The problem is that ideological thinking may not correspond to the complexities and inconsistencies of the real world. That is obvious in politics, but the principle also applies to science. While scientists do not believe that they think ideologically, they often pretend to know more that they do. For this reason, theories that seem to explain everything can take on the cast of belief” (p 39). Paris discusses various issues, such as psychopathology and normality, why DSM-5 adopted its ideology, and ideology and hubris. He states that by rejecting many traditional roots, neuroscience-based psychiatry is firmly reductionistic (p 40). He also states “Given the limited state of evidence in support of spectra, the adoption of RDoCs (Research Domain Criteria) by NIMH can only be described as ideological” (p 40). I can only add, “Finally someone said so.” He also reminds us that we are no closer to understanding the etiology and pathogenesis of mental disorders than we were 50 years ago and “For that reason, DSM-5 had no choice but to continue with a provisional and pragmatic system based on phenomenological observation” (p 41). In conclusion, Paris suggests that “The ideology of DSM-5 exaggerates what we know, and reflects impatience for a time when psychiatrists can practice in the same way other physicians,” and that “The claim that we can apply neuroscience to diagnosis, creating valid spectra of psychopathology, is little but hubris” (p 43). These 3 chapters are the most informative and readable parts of this volume.
The titles of the following 3 chapters, “The biopolitics of defining ‘mental disorder’” by Warren Kinghorn, “Establishing normative validity for scientific psychiatric nosology: the significance of integrating patient perspective” by Douglas Porter, and “The paradox of professional success: grand ambition, furious resistance, and the derailment of the DSM-5 revision process” by Whooley and Horwitz, amply describe their focus. Kinghorn actually argues strongly and convincingly that the future DSM editions, “at least until the development of much more detailed and robust ground-up accounts of neurobiological and psychological function than we have now, should not include a definition of mental disorder” (p 59). Whooley and Horwitz discuss the derailment of the originally intended dimensionality of DSM-5 diagnoses by the APA Assembly. They feel that this derailment damaged psychiatry’s professional standing. Yet, I think that remains to be seen, as anybody who has been around during previous DSM revisions would probably say.
The last 4 chapters (as I suggested, the last treatise, “Conclusion” by James Phillips, basically summarizes the volume) include “DSM in philosophyland: curiouser and curiouser” by Allen Frances; “Overdiagnosis, underdiagnosis, synthesis: A dialectic for psychiatry and the DSM” by Joseph M. Pierre; “What does phenomenology contribute to the debate about DSM-5” by Aaron L. Mishara and Michael A. Schwartz; and “The conceptual status of DSM-5 diagnoses” by James Phillips again capture their content in their titles. The chapter by Allen Frances is, unfortunately, a bit more about Frances than about other things. Yet, he reminds us that “Biological psychiatry has failed to produce quick, convincing explanations for any of the mental disorders” (p 96). I would suggest that, unfortunately, so did any “other” branch of psychiatry. Allen Frances also points out the possible concerns about the revised system, such as the unfortunate concept of comorbidity, which seems to be mostly gone from the DSM-5, heterogeneity within diagnoses, and the possible misuse in diagnosing conditions at the border of normality and criminality (p 102). Mishara and Schwartz, in their eloquent treatise that did not find phenomenology useful, discuss the statement of Steven Edward Hyman that “it is probably premature to bring neurobiology into the formal classification of mental disorders that will form the core of DSM-V…” Interestingly, 2 diagnoses in DSM-5 (Neurocognitive disorder due to Alzheimer’s disease and Narcolepsy) actually include some neurobiology. In the conclusion of his chapter on conceptual status of the DSM-5 diagnoses, Phillips writes that “But for clinical use, it is perfectly conceivable that, in the psychiatry of the future, we will conclude that many of the current psychiatric categories, for all their causal messiness, will prove to be the most practical ways to divide and classify the world of psychopathology. In the latter vein, Kenneth Kendler and Michael First1 argue that psychiatric nosology is not ready for a paradigm shift and that for now we should stick with improving the current categories in a progressive, iterative manner” (p 156). This seems to be a reasonable statement to conclude this volume with.
This is an interesting and intellectually provocative book that will be appreciated and enjoyed by many who like to brood about the diagnosis of mental illness, its meaning, construct, and utility for ourselves and our patients. There are 2 issues I would like to point out. First, the authors should have waited a bit longer—until the publication of the DSM-5—to see the final product. It is easier to discuss the real final product than its imagined content. The second issue applies more to all critics, not just the ones who are part of this book: Nobody has, unfortunately, offered us any better alternative so far (including the RDoCs). Paraphrasing the famous Winston Churchill dictum about democracy, “DSM is the worst form of diagnostic system/classification, except for all those other systems that have been tried from time to time.” Sad, but true.
- Kendler KS, First MB. Alternative futures for the DSM revision process: iteration vs. paradigm shift. Br J Psychiatry. 2010;197:263–265.
Annals of Clinical Psychiatry ©2014 Quadrant HealthCom Inc.