The New York times has a short, but fascinating piece on the preparation of a revised version of of one of the world’s most influential documents – the Diagnostic and Statistical Manual of Mental Disorders, produced by the American Psychiatric Association. The DSM not only guides the diagnosis (and thus the treatment) of mental illness across the United States and much of the rest of the world (including Australia), it is regularly quoted in court decisions and influences things like insurance coverage (in the US).
One short snippet in the article indicates some of the stakes, as well as the risks posed by the subversion of the process for commercial gain:
One significant change would be adding a childhood disorder called temper dysregulation disorder with dysphoria, a recommendation that grew out of recent findings that many wildly aggressive, irritable children who have been given a diagnosis of bipolar disorder do not have it.
The misdiagnosis led many children to be given powerful antipsychotic drugs, which have serious side effects, including metabolic changes.
“The treatment of bipolar disorder is meds first, meds second and meds third,” said Dr. Jack McClellan, a psychiatrist at the University of Washington who is not working on the manual. “Whereas if these kids have a behavior disorder, then behavioral treatment should be considered the primary treatment.”
I have no knowledge, one way or the other, about the merits of the case for defining this new disease. But it’s not hard to see the potential for financial incentives to encourage the acceptance, or not, of revisions like this. If you’re a drug company who sells psychotropic medications, reclassifying a bunch of patients to another category where drugs are less widely prescribed might be considered a bad thing. If you represent somebody who provides psychosocial treatment, there are financial incentives in the other direction.
I do have to wonder how the entirety of the DSM process would stand up to the kinds of scrutiny placed on the IPCC.
Ha! That’s easy – it couldn’t. Comparing the science of climate change with that of psychiatric diagnosis would be like comparing… two things that are very dissimilar. And I speak as a researcher in the area!
If this re-write is a wholly American affair then there must be some nervous foreign health administrations at the prospect of the US drug lobby pressuring for the wider definitions of new and existing somatic conditions.
On the other hand I did hear one of the principals (psychiatrist)involved, on PBS Newshour, state that there would a tightening of definitions. Here’s hoping.
Who says you’ll “never read” the DSM? (Guilty former reader here.)
Although my favorite mental illness came IIRC from a different medical dictionary (it’s all so long ago now) and involved, among other peculiar signs and symptoms, a species of group hyper-suggestibility, which was said to be especially endemic in certain regions of the South Pacific. Good luck making that case. Ah, wish I still had my notebooks from back then. Curse you, various moving companies!
And, you think the slivers of half-light shone on the bugs of the IPCC to date count as “scrutiny”?
I hear that, while gambling addiction has been added to the disease list, internet addiction did not make the cut.
So we are off the hook for now.
The DSM has spawned a major industry on the internet which is sites, e-books and online therapy for those who have been entangled with or are trying to escape an intimate with a cluster B personality disorder. DSM revisions are apparently deeply political and involve horse trading around symptoms of associated disorders as much as the recognition of new diagnoses.
Will the new version of the DSM declare clinically disordered persons who successfully pass themselves of as real psychiatric patients?
That way the psychiatric profession won’t have to deal with any more nonsense from sceptics who suspect that much psychiatry is just moonshine.
‘I do have to wonder how the entirety of the DSM process would stand up to the kinds of scrutiny placed on the IPCC.’
On the occasions when such scrutiny took place, it didn’t do any good. One dark episode involved the APA’s decisions to classify PMS as a mental illness and to widen the classification of masochism to ‘masochistic personality disorder’ (to encompass any kind of self-defeating or self-sacrificing behaviour).
Despite letters and petitions from hundreds of (mostly female) mental health professionals, saying that among other things the classifications pathologised women and absolved the perpetrators of gender/domestic violence by blaming the victim, the all-male psychiatric panel went ahead. So ridiculous was the ‘scrutiny’ process that the APA reluctantly allowed a team of female psychologists to attend APA meetings on the classification, but they were not allowed to speak.
Imagine the IPCC getting away with anything like that.
It’s funny that you mention the controversy about the IPCC; there’s been plenty of scrutiny of the DSM-V on psychology and psychiatry related blogs (and even on mainstream pieces from other psychology) and there’s been quite a lot of controversy. Remember that this release is a draft version of the DSM-V, and that the point of the draft is to get feedback from people outside of the process, so don’t automatically assume that this is the completely finished version.
Some commentary by various psych blogs: Furious Season’s Phillip Dawdy (a psych patient advocate), Dr Petra Boynton (psychology PhD and sexuality expert), and several posts by Vaughn Bell of Mind Hacks about various controversies. All in all, though, the reaction to the DSM-V in the psych world has been reasonably positive – it’s mostly an improvement on what’s currently there and it’s introducing some good new innovations, but it’s by no means perfect.
DSM – yup its a fascinating read.
Robert, re yr IPCC v DSM comparision – sustained pressure and lobbying saw the removal of homosexuality from the DSM as a psychiatric pathology over many years. I’m sure certain orthodoxies around climate change will change across the decades as well. (Weird if it doesn’t). In the former case, the behaviour stayed the same, just the contextural understanding of that behaviour shifted though there are still a band of hard corers that see this shift as a gay lobby conspiracy.
I wonder how our understandings will shift around the latter over time?
I’m guessing a few of the things we see as CC ‘pathologies’ will become normalised, and lots more climate phenomena will understood more fully, as deviations from the norm and thus worthy of study and intervention.
Oh and btw, all this apocalyptic talk is literally making some of us freak out!
http://uninews.unimelb.edu.au/view.php?articleID=5082
The DSM is a joke, and has been for a long time. It’s basically been captured by a range of vested interests, and is inextricably linked to the funding of treatment by insurance companies in the US (and elsewhere).
Even compared to the diagnostic cookbooks of classical psychiatry, the DSM appears as a loser. It has no sound criteria for ‘disorder’ itself (other than some vague and imbecilic gestures to selective normative standards) and has such a confused grasp of humans themselves (see, for instance, the split between Axis I and II disorders) as to be clinically useless. Sadly, this abomination has become the lingua franca for clinicians who need a common language for courts, insurance purposes, etc. But there can be no serious talk of an ‘improved’ or ‘revised’ DSM when the fundamentals are so wrong. It’d be like speaking of a ‘revised’, ‘improved’ flat tyre.
“Sadly, this abomination has become the lingua franca for clinicians who need a common language for courts, insurance purposes, etc)”
I think your attitude towards many clinicians is a little too positive. Many clinicians use it because it’s a simple way of diagnosing things if you don’t understand any theory behind the disorders, and that’s pretty much what they’re taught (it’s also worthwhile noting that the DSM doesn’t claim to be anything but a check-list, as is stated in the manual — the fact that it gets used as a “theory” of many things is simply incorrect usage). The fact that it can be used as a lingua franca is a positive.
To me the real problem with the DSM in places like Australia is that people think far too highly of it and the clinical college has too much power. This means anything in it is taken like gospel, and the scope of work clinical psychologists do is far too broad — they’re often doing stuff they have no idea about (e.g., educational psychology in schools, grief counselling, and more recently, replacing clinical neuropsych guys in hospitals). If you want a good laugh, have a read of the language section, then find a clinical psychologist under 35, and ask them what the difference between a noun and a verb is. Now wait until the clinical colleges pushes to have their guys replace speech therapists and other such people. Similar results can be found by quizzing them about basic neuroanatomy and basic neuorophysiology.
THR @10: quite right too. In other terms the DSM is ontological without epistemological foundation. To violate these delicate philosophical notions and put it in plainer terms: ontology is a list of what we know; epistemology is a theory of how we can and know what we claim to know. The former is meaningless without the latter.
Much of contemporary psychiatry is based on what I call ‘suck it and see’ diagnosis which is where inpatients are given a range of medications and then a diagnosis is made retroactively once a medication appears to have some sort of salutory effect. Very crude.
As to the current area of public fascination with cluster B personality disorders my own treatment is ethical rather than therapeutic: tell the truth. More pointedly, stop lying. Most of their character disorders stop once they make that commitment because most of how they act out involves untruth, chronic lying and manipulation. Medications can be useful with such people, especially the anti-anxiolytics, because they are deeply fearful of, and thereby anxious about, experiencing their feelings and having them exposed to others. I wish someone would pay me a rebated $280 p.h. for exercising that sort of insight.
i hope to have fun reading the DSM Robert, as of this morn i appear to be a student again, but as the whole process has taken place over the interwebs, with the intervention of only one stamp and two phone calls, it seems a little unreal. i miss the bustle of enrolment day.
There have been DSMs on the office bookshelves of my places of employment for much of the last ten years. It was a little disconcerting to see a couple 19 year olds pull it down, turn to a set of pages and tell us which child or forensic psych had given them which diagnosis. I am not certain, but in many cases like that it seemed that the book helped confuse our clients. after it happened a few times i took to putting it in awkward nooks of the bookcases, i did that with the MIMs too after a young man took me on a tour of all the drugs he could remember being prescribed since his first dose of ritalin.
thanks too for the above comments, i’ll try to bear them in mind as i enter world of labrats and such. In the mean time i gotta track down a copy of frontier Psychiatrist by Wayne and Shuster (?). failing that a turntable so i can play my old vinyl.
Well that was easy.
old school sexism dressed up as humour warning.
thanks