Shooting diagnostic fish in the psychiatric barrel: part one

Does psychiatry pathologize normal behavior, inventing diseases with the reckless abandon of Dr. Unheimlich? Is the DSM an atlas of cultural bias, without a shred of tissue-based evidence to support it? Yes, says Dr. Irwin Savodnik, in this provocative, satirical LA Times editorial. He blasts the APA and its diagnostic manual:

...in 1994, the manual exploded to 886 pages and 365 conditions, representing a 340% increase in the number of diseases over 42 years.

Nowhere in the rest of medicine has such a proliferation of categories occurred. The reason for this difference between psychiatry and other medical specialties has more to do with ideology than with science...Where, though, is the diseased tissue in psychopathological conditions?

Unlike the rest of medicine, psychiatry diagnoses behavior that society doesn't like...

One of my supervisors was fond of such arguments. He would whip out his pocket DSM during rounds, recite criteria for cyclothymia or dysthymia, and ask, "How is this a disease?" It's easy to shoot diagnostic fish in the psychiatric barrel - in fact, one can make a career of it. It's not hard to see why.

Many psychiatrists agree that things have gotten out of hand. Here's Dr. Andreasen, an early author of DSM, in the New Scientist. She explains how DSM was conceived, and how it expanded. She's very critical of DSM now:

DSM is based on careful observation but it is just not complete - it was never meant to be the absolute truth. That's what people miss. We put in enormous caveats: use this book as part of a total clinical evaluation, use with great care, for use only by qualified doctors, and so on. But it represented a huge shift. It introduced diagnostic criteria. We wanted to make a statement about the importance of making psychiatry more objective.

One example is the description of schizophrenia: in DSM II, it is about five sentences. In DSM III, there are four or five pages of description followed by diagnostic criteria. We also managed to take out neurosis, which was important because we thought it was especially vague - and we put in a new approach to classification so we could incorporate medical and psychosocial elements of a clinical evaluation when it came to reaching a diagnosis.

Before the ink was dry on the first DSM, problems were apparent. Because the DSM-described behaviors have a social component and occur in a social context, they reflect biases in our culture. DSM has always been a work in progress (and it always will be). We must use extreme care when we use the term "pathological." Here's more from New Scientist:

In psychiatry, the cost of erroneous scientific theories can be incalculable. Get things wrong (or even only half right) and once adopted by the profession it can take years to weed them out. The result can be millions of shattered lives...

Some of the world's leading psychiatrists believe that this is just what has happened in their craft today...

Now into its fourth edition, DSM was meant to help doctors diagnose mental illnesses by categorising diseases according to a small number of telltale signs. What has happened, say Nancy Andreasen and many other psychiatrists who have helped to write DSM, is that it has become the main reference for diagnosis, something it was never intended to be. Now psychiatrists everywhere are reluctant to diagnose an illness unless its symptoms can be found in DSM...As the revisions to DSM multiplied, so did the criticisms: the manual's diagnostic categories were called prescriptive, arbitrary and driven by literal-mindedness. They did not reflect all opinions in psychiatry, said the critics, nor even a complete set of all psychiatric disorders worldwide.

This is serious criticism, and points toward some possible solutions. Clearly, we have tremendous work ahead of us.

But Dr. Savodnik seems to say: let's toss out the whole enterprise. Why does he send up Seasonal Affective Disorder? He doesn't cite any research or diagnostic criteria that trouble him. Satirized and oversimplified, his take on the disorder makes nice holiday copy, and illustrates his chief complaint: that APA is "selling mental illness," when there isn't any such thing.

...which brings me to part two. Next!