shooting diagnostic fish in

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.