The fifth edition of the Diagnostics and Statistical Manual (DSM-5) was recently released. This is the standard reference of mental disorders and psychiatric illnesses released by the American Psychiatric Association (APA).
As with previous editions there is a great deal of discussion and wringing of hands over the details – which disorders were created or eliminated. For example hoarding is now considered its own disorder, rather than part of obsessive compulsive disorder (it has its own reality TV show, why not its own DSM diagnosis?).
This time around, however, the debate over the DSM goes much deeper than the particulars of specific diagnoses. The real debate is about the very existence of the DSM – its validity and utility. While this discussion is nothing new, it has taken on an unprecedented dimension with the rejection of the DSM by the National Institutes of Mental Health (NIMH). Director Thomas Insel wrote:
The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.
Psychiatry is arguably the least science-based of the medical specialties. Because of that, it comes in for a lot of criticism. Much of the criticism is justified, but some critics make the mistake of dismissing even the possibility that psychiatry could be scientific. They throw the baby out with the bathwater. I agree that psychiatry has a lot of very dirty bathwater, but there is also a very healthy baby in there that should be kept, cherished, nourished, and helped to grow – scientifically.
Common criticisms in the media
- We are over-medicating our children, producing a generation of drugged zombies.
- We are using medication indiscriminately for people who don’t fit the diagnosis (i.e. antidepressants for people who only have normal mood fluctuations and life problems).
- Antidepressants lead to violence and suicide.
- Psychotropic medications all have terrible side effects.
- Antidepressants are no better than placebo.
- Psychotherapies are no better than talking to a friend.
- Electroconvulsive therapy (ECT) is a barbaric, damaging assault with no redeeming value.
- And we all remember how Tom Cruise attacked Brooke Shields on the issue of postpartum depression.
Thomas Szasz: Mental illness is a myth
Thomas Szasz goes even further: he rejects the whole concept of mental illness and considers it a plot to interfere with people’s human rights. He says:
- Psychiatric diagnoses are not valid because they are based on symptoms rather than on objective tests. (Steve Novella has pointed out that there are other well-established diagnoses like migraine that cannot be verified by any objective tests.)
- Mental illness is a myth: unusual behavior does not constitute a disease.
- Psychiatric diagnoses are an arbitrary construct of society to facilitate control of individuals whose behavior does not conform.
- Involuntary commitment is never justified even for the protection of the patient: patients always have the right to refuse treatment even if that means they will die. (more…)