The Book We Love to Hate

The Book We Love to Hate

Why DSM-5 Makes Nobody Happy

March/April 2014

The Diagnostic and Statistical Manual of Psychiatric Diagnoses (DSM) has never been exactly a page turner in any of its iterations (I, II, III, III-R, IV, IV-TR, and now 5), nor have its hundreds of authors over the decades ever been short-listed for the Nobel Prize in literature. The thing’s a slog to read, and it gets longer, sloggier, and pricier with every edition. DSM-II, at 134 pages, cost about $3 in 1968; DSM-5, the latest version, at 947 pages, is priced at $199 by the American Psychiatric Association (APA)—though you can now get it discounted on Ebay for $120.46, free shipping included.

And yet, from small, insignificant beginnings in 1952, when almost nobody read it, it’s become a kind of sacred literary monster—as well as a massive, hernia-inducing brick of a book—that’s read avidly, if not a bit fearfully, by millions of mental health professionals, insurance company employees, drug industry executives, physicians, social workers, government employees, educators, lawyers, law enforcement and public health officials, adoption agency staff, and a surprisingly large swath of the general public. Over the years, it’s become one of the most studied, most professionally cited, and most culturally influential mental health books ever published.

It’s also the most controversial, perhaps the most detested, and certainly the most debated of any mental health classification scheme—any disease nosology—ever devised. Still, the outpouring of rage against the DSM-5 among mental health professionals is startling in its volume and scope—a virtual in-house outbreak of oppositional defiant disorder, and surely the most intense, widespread, and sustained challenge to DSM’s legitimacy in its 62-year history.

The protesters on record include 15,000-plus signatures on the Coalition for DSM-5 Reform petition, sponsored by the APA’s Division 32 (Society for Humanistic Psychology), as well as 50-something other mental health organizations (many of them divisions within the APA), an ad hoc group called Boycott the DSM-5, and many thousands more who’ve voiced their unhappiness on both journalistic and professional websites.

Even more surprising is that the widely acknowledged chief spokesperson for the opposition is none other than Allen Frances—perhaps the last person you would expect to trash this latest, biggest DSM. An eminent psychiatrist, researcher, and writer on a host of issues (including personality and anxiety disorders, chronic depression, schizophrenia, AIDS, and psychotherapy), former chair of the psychiatry department at Duke University, and founder of two psychiatric journals, he himself helped prepare DSM-III and DSM-III-R, and, in what would be the capstone of an illustrious career, chaired the task force that published DSM-IV in 1994. Indeed, in a New York Times article in April of that year, author Daniel Goleman called him “perhaps the most powerful psychiatrist in America.” And yet today, he’s become a de facto spokesperson for the anti-DSM movement.

At this point, a short digression about the 5 in DSM-5 seems necessary: the producers of the new manual prefer the Arabic numeral 5 to the Roman V, because the latter, they claim, is “limiting.” In other words, it’s awkward to use when disseminating revisions electronically—i.e., DSM-5.1, DSM-5.2, and so on—which they plan to do, possibly going up to DSM-5.102 and beyond, for all we know. This means that every time there’s a tiny blip on the diagnostic scene, it can be duly entered into an online revision. No more waiting a decade or more! Besides, as one writer for pointed out, in a techie/digital world, Roman numbers just aren’t cool.

Interestingly, Frances—whose interview with the Networker appears on page 32—was drawn into the debate by another DSM shepherd: Robert Spitzer, the chair of the DSM-III Task Force. Spitzer first attacked the DSM-5 authors in 2008 for imposing a nondisclosure agreement on contributors, thereby allowing them to operate in confidence and not let in any outsiders—even him, the founding father of the entire modern, scientifically aspirational DSM industry. “When I first heard about this agreement, I just went bonkers,” Spitzer was quoted as saying in the New York Times in 2008. “Transparency is necessary if the document is to have credibility, and, in time, you’re going to have people complaining all over the place that they didn’t have the opportunity to challenge anything.”

Spitzer certainly got it right about “people complaining all over the place.” However, there’s something about the attacks on DSM-5 that bring to mind the famous Yogi Berra comment—“it’s déjà vu all over again”—because what most critics object to are the same features, more or less, that have been true of every edition since DSM-III in 1980. Spitzer’s manual was the first to describe and categorize mental disorders as biomedical diseases, which was intended to—and did—reanoint psychiatry as a medical specialty, rather than a languishing psychoanalytic backwater, thus probably saving it from professional irrelevance and oblivion. As the tale goes, once diagnoses were medicalized, they could be medicated, meaning medical doctors could prescribe lots of expensive psychotropic drugs, guaranteeing vast profits to the drug industry. Ever since, according to DSM’s large and growing crowd of hecklers, the DSM, APA, and Big Pharma have been in flagrante delicto, all in bed together, committing indecent acts of diagnostic inflation and mutual back-scratching. It doesn’t help the manual’s reputation for untainted scientific objectivity that around 70 percent of DSM-5 Task Force members and 56 percent of Work Group members hold stock or serve on boards or as consultants to the pharmaceutical industry.

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