The fifth edition of the "psychiatric bible," the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), appeared this year - to an unaccustomed storm of controversy, not merely in antipsychiatry bestsellers but in high administrative offices. Thomas Insel, director of the U.S. National Institute of Mental Health announced that the Institute would henceforth ignore all the DSM's diagnoses when determining research funding because the manual's "weakness is its lack of validity."
That's a pretty devastating pronouncement when you consider that the DSM is not only consulted worldwide, it is a basis for court decisions and accepted health insurance claims as well as pharmaceutical research. More, it defines what is normal for the human mind and what is not.
DSM-5 was the first revision in twenty years, so there may have been pent-up demand for a discussion of what exactly has been learned or accomplished. Criticism focuses on several key areas:
Causes of mental illness. The manual attempts to apply science to psychiatry, but it is not clear how well that works. Only three percent of listed disorders have any recognized biological cause. As the Financial Times puts it,
The causes of the remaining 97 per cent - and this includes depression, anxiety, schizophrenia, attention deficit hyperactivity disorder (ADHD), bipolar and all personality disorders are not known. The theory that chemical imbalances cause mental illness - that a serotonin deficiency causes depression, for example - is unproven. Billions of research dollars have been spent on trying to establish a link between neurotransmitters and mental disorder, and the attempts have failed. For all the scientific terminology, psychiatric diagnoses are based on subjective judgments.
Many mental diseases listed were determined by vote or committee consensus, not research. In fact, there is no rigorous research that identifies most mental diseases in the manual.
Inflation of disorders. Nonetheless, there was a dramatic increase between the first and the fourth edition in disorders listed, from 106 in DSM-1 to 374 in DSM-4. Also, criteria have grown ever more inclusive, driving apparent "epidemics" of depression, bipolar disorder and ADHD, with no real public accountability. The number of pages increased as well, from 130 in the first 1952 edition to 991 pages in the fifth.
Transparency. It is hard to say how many psychiatrists, psychotherapists, counsellors and nurses depend on DSM diagnoses for their living, but transparency may be an unmet challenge when personal well-being is at stake.
Medicalising normal problems. Perhaps the most serious accusation is, as the Financial Times puts it, "By gradually slackening its criteria the DSM has estranged us from our eccentricities, our survivable rough patches, our shyness and sorrows, and made them sound like diseases." Allen Frances, the leader of DSM-4, admits that it has resulted in "medicalizing" normal human problems. As one reviewer puts it, "Fully a quarter of the people in the US are regarded as suffering from a mental illness. People are tagged as mentally unfit, when in fact they are often just having a hard time with life."
Materialism at the core
Psychiatry adheres to a myth, says James Davies, author of Cracked: Why Psychiatry is Doing More Harm than Good, "that mental suffering is caused by our biology." As Joseph Brean notes in the National Post, "Even its target, the mind, is not seen as a real thing itself, but a metaphor for the doings of the brain." Davies doubts psychiatry can escape the resulting trap: dependence on research cash from drug firms who promote the materialist, chemical view. Unsurprisingly, critics among psychiatrists are a minority. Meanwhile, some of us ask, if there is so much to be said for materialism, why is the evidence not there? In this and so many other areas?
As for the DSM's future, University of Toronto medical historian Edward Shorter says, "I don't think there will be a DSM-4, I think the whole thing is going to collapse." Perhaps so, given that DSM-5 has been reduced to ridicule as a new dystopian novel that "takes the form of a dictionary of madness."
But the dream of total materialism in science will not die so easily. Indeed, in an effort to dampen criticism, the president-elect of the APA spoke of his hope for a diagnostic system "that more directly reflects modern brain science". Let's hope that doesn't mean: Same time next week, but this time with fMRI imaging and CATSCAN. That's already been exploded too.
Recent books on the DSM and related issues in psychiatry:
The Book of Woe: The DSM and the Unmaking of Psychiatry, by Gary Greenberg
Saving Normal: An Insider's Revolt Against Out-Of-Control Psychiatric Diagnosis, DSM5, Big Pharma, and the Medicalization of Ordinary Life, by Allen Frances (chaired the task force for the fourth DSM)
Cracked: Why Psychiatry is Doing More Harm Than Good, by James Davies
Our Necessary Shadow: The Nature and Meaning of Psychiatry, by Tom Burns