Prognosis Negative Psychiatry and the Foibles of the Diagnostic and Statistical Manual V (DSM-V)
Sorboro, John, Skeptic (Altadena, CA)
SPENT TOO MUCH MONEY ON PRADA LOAFERS OR Gucci handbags? Still upset over not getting to play starting quarterback for the big game your senior year? Maybe you're overcome by the desire to surf the web, which your boss refuses to acknowledge is disabling. If so, you may qualify as mentally ill, stricken by a psychiatric disorder as defined by The Diagnostic and Statistical Manual of Mental Disorders (AKA, the DSM, or "The Psychiatrist's Bible") when the new (5th) edition (DSM-V) is released in 2013.
The DSM-V will officially sanction suffering and dysfunction like never before, with new disorders such as "Post Traumatic Embitterment Disorder," "Compulsive Shopping," and "Internet Addiction Disorder," all being considered for addition to the official list of psychiatric disturbances. The folks writing the new DSM-V are even considering a new classification of "prodromal" disorders, which means you may qualify for diagnosis of a mental disorder just based on the hunch of your psychiatrist. No one knows how many disorders will be added yet, but if history is any indication (the number of psychiatric diagnosis has nearly doubled with each edition of the DSM), you may qualify for a newly acknowledged disorder and maybe 3rd party payers will reimburse me, a psychiatrist. How did we get to this stage?
The Origin of the DSM
The first edition of The Diagnostic and Statistical Manual was released in 1952. The manual was 130 pages long and listed 106 mental disorders. (1) It was grounded in psychodynamic psychiatry, which relied heavily upon the writings of Freud and others, as did the 2nd edition published in 1968. Unlike today, symptoms were not specified in detail for each disorder. Psychic anxiety and the analytic concept of neurosis were critical in conceptualizing almost all psychopathology. Until the mid-1970s, a model informed by psychoanalysis, sociological thinking, and limited biological knowledge was the organizing paradigm for American psychiatry. However, this model did not clearly lend itself in helping define who was "sick" in the collective eyes of psychiatry. In part this failure led to a crisis in the legitimacy of psychiatry by the 1970s. (2)
Adding to this failure was the famous experiment exposing the subjectivity of psychiatric evaluations conducted by the psychologist David Rosenhan and his colleagues, reported in the journal Science. (3) Eight experimenters, including a psychology graduate student, three psychologists, a pediatrician, a psychiatrist, a painter, and a housewife were instructed to attempt to gain psychiatric hospital admission by feigning symptoms during psychiatric assessment. Each claimed to be hearing voices that were often unclear but which seemed to say the words "hollow," "empty," and "thud." No other psychiatric symptoms were claimed and apart from giving false names and employment particulars, further biographical details were truthfully reported. If admitted, the pseudopatients were asked to "act normally" and report that they felt fine and no longer heard voices. None had a history of mental illness.
All eight of Rosenhan's subjects were admitted, seven with a diagnosis of schizophrenia and the last with manic-depression. Once admitted and diagnosed, the pseudopatients were not able to obtain their release until they agreed with the psychiatrists that they were mentally ill and took antipsychotic medications. Rosenhan's article exploded in controversy that ultimately led to the publication of the DSM-III in 1980. With it, the essential focus of psychiatric nosology changed to a research-based atheoretical descriptive model. A new paradigm was born.
Robert Spitzer may be the second most influential psychiatrist of all time. Regardless, I do not recall ever hearing his name mentioned even once during all my training. Unlike Freud, Jung, or Kernberg who brought interesting but arguably dubious, speculative philosophical models to psychiatry, it was Spitzer who was mostly responsible for the DSM-III, and it was he who brought claims of scientific credibility to the field. …