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The Book We Love to Hate - Page 3

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Defending DSM-5

At this point in the DSM contretemps, a little vagrant wavelet of sympathy might surface for the poor, besieged producers of DSM-5, whose worst sin seems to be that, like Don Quixote, they just dreamed the impossible dream: to establish DSM on firmer, more scientific grounds, to clean up some of DSM-IV’s shortcomings (the inadequate treatment of childhood and adolescent disorders, for example), and to help clinicians more effectively and accurately treat their clients. As for the accusation that they’re money-grubbing shills for Big Pharma and the APA, not even Frances believes that. “I know the people working on DSM-5 and know this charge to be both unfair and untrue,” he wrote in a Psychology Today blog. “Indeed, they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies. Theirs is an intellectual, not financial, conflict of interest that results from the natural tendency of highly specialized experts to overvalue their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM-5 to real-life clinical practice (particularly in primary care where 80% of psychiatric drugs are prescribed).”

Darrel Regier, vice chair of the DSM-5 Task Force—interviewed by the Networker on page 32—appears a mild, unassuming researcher, slightly bemused that the release of what was intended to be a more accurate, nuanced, and rigorously researched manual has raised such an uproar. Director of the APA’s research division, he spent 25 years at NIMH heading research divisions in epidemiology, prevention, clinical research, and health-services research. Like other DSM producers and defenders, he knows perfectly well that psychiatric diagnosis is often inherently ambiguous and that the science behind the classification system isn’t all it might be. “We are faced with an interesting situation of having what are well-known deficiencies in the current diagnostic system,” he said with some understatement in a Medscape Medical News interview. A lot of what was going into DSM-5, he admitted, “has not been tested as well as we would like. The current problem is that because the DSM has so dominated research practice for the last 30 years, nobody would even think or get funding to test different diagnostic criteria until they’re really adopted by the DSM.”

In other words, build it and they’ll come—but not before it’s embedded in the brick and mortar of the DSM edifice. Regier regards DSM-5 not as The Law, and certainly not any kind of bible of psychiatry, but as a work in progress, “a set of scientific hypotheses that are intended to be tested and disproved if the evidence isn’t found to support them.” And, again, that’s why it’s DSM-5, not -V: the manual will be a “living document,” which can be regularly revised, “in much the same way as is done with software updates.”

The authors of DSM-5 do lay claim to a genuine innovation: describing many mental disorders on a spectrum from almost-normal to obviously disturbed, determined according to quantitative measures of relative severity or mildness. The idea makes intuitive sense: most mental states, ordered or disordered, exist along a continuum and vary according to how long they last, how powerful or debilitating or animating or life-altering they are, and how much they bleed into other such states; for example, it’s possible to feel both happy and sad, mad and anxious at the same time. DSMs III and IV had seemed increasingly arbitrary, enclosing ambiguous and changeable experiences into rigid categorical cells, either present or absent: either you had major depressive disorder, or you did not, period.

But to critics, the new dimensional aspect exhibits, upon closer inspection, its own kind of fishiness: it resembles an updated replay of the psychodynamic principles of DSMs I and II, in which normal and abnormal didn’t absolutely exclude each other, with one potentially dangerous difference. “Conceiving of mental disorder in a spectrum harkens back to the psychoanalytic tradition that the profession had spent decades shedding,” writes Joel Paris in “The Ideology behind DSM-5,” a chapter in Making the DSM-5, which he edited. But unlike the psychoanalytic tradition, “this new dimensionality is rooted in quantification. . . .

The conviction that mental disorder is a point on a continuum flows directly from a neuroscience-based dimensional model.” Within this odd merging of psychoanalytic and neuroscience concepts, however, “there is no essential difference between normality and psychopathology. The danger of the DSM-5 ideology is that it extends the scope of mental disorder to a point where almost anyone can be diagnosed with one and treated accordingly.” And it supposedly adds the imprimatur of biological science to this diagnostic spread.

Pity the gallant producers of DSM-5, just trying—again—to make psychiatric diagnosis more scientifically respectable and more helpful to clinicians, to make what’s in effect a big dictionary of abstractions decently comport with real-world phenomena. Of course, whether you believe they failed or made strides in the right direction (DSM-5 does, in fact, have its own cheering section out there), everyone can agree that the great paradigm shift didn’t happen. If you believe Thomas Kuhn—who introduced the concept of paradigm shift in his, well, paradigm-shifting book The Structure of Scientific Revolutions—science proceeds not so much in incremental, linear steps toward ever greater knowledge and understanding, as by unexpected and fundamental changes in basic assumptions about the world and what constitutes reality. Such shifts are triggered by a crisis of confidence, when old theories and worldviews increasingly can’t be squared with new discoveries and observations; the more inherently complex the field, the greater the problem with the fit of an outmoded theory. Eventually, after a period of sturm und drang—challenges by visionaries and inventors, resistance and rejection by the old guard, appeal to a younger generation—the great new thing succeeds and fundamentally alters the way everybody looks at reality.

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