DSM: A History of Psychiatry’s Bible

Here are some highlights from this 2021 book by sociologist Allan V. Horwitz:

* The Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association pervades our culture. Since publication of the manual’s third edition in 1980, its diagnoses define what mental disorders are considered legitimate, how patients conceive of their problems, who receives government benefits, and which conditions psychotropic drugs target and insurance companies will pay to treat. They also delineate the curriculum that is taught to psychiatrists and other mental health professionals, the diagnoses that researchers and epidemiologists explore, and the psychic problems that public policies attempt to remedy.

* Diagnoses from the Diagnostic and Statistical Manual of Mental Disorders (DSM) have become part of our culture. Environmental activist Greta Thunberg is widely known to have Asperger syndrome; one of her adversaries, Donald Trump, is commonly seen as displaying a narcissistic personality disorder. The singer Mariah Carey has discussed her struggles with bipolar disorder, the same condition dramatized in the main character in Homeland, Carrie Mathison. Lady Gaga has spoken about her struggles with posttraumatic stress disorder (PTSD). TV mobster Tony Soprano seeks treatment for panic attacks, while his son is suspected of having attention deficit / hyperactivity disorder (ADHD). Susanna Kaysen, the author of the best-selling memoir Girl Interrupted, discovered she had borderline personality disorder while reading the DSM-III in her local bookstore. Many patients enter therapy already knowing what diagnosis they expect to receive.
The centrality of DSM diagnoses is a new phenomenon, arising only after the third edition of the manual was published in 1980.

* The importance of the DSM for psychiatry is unique among medical specialties. Other areas of medicine commonly rely on biological markers that confirm or refute a diagnosis of some disease: cardiologists use PET scans to see whether a heart has tissue damage, nephrologists take x-rays to search for a kidney stone, oncologists perform biopsies to detect cancerous cells, and general practitioners employ blood tests to establish levels of cholesterol or blood pressure. Psychiatrists, however, have none of these tools. The lack of confirming markers for any common mental disorder means that diagnosis in itself has an outsize role in psychiatry compared to other branches of medicine. Although most of the DSM diagnoses lay out detailed symptom criteria and specific inclusion and exclusion rules, in actuality, patient self-reports and, sometimes, clinical observations constitute
psychiatry’s diagnostic resources. No independent criteria can verify the accuracy of a clinician’s assessment of a mental disorder.

The American Psychiatric Association owns the DSM, which allows the organization to monopolize the diagnoses of mental disorder for all mental health professions.

* Aside from using the DSM for rhetorical and institutional purposes, few psychiatrists consider its diagnoses accurate portrayals of underlying natural phenomena. They do, however, religiously use them for educational training, obtaining reimbursement for treatment, submitting grant applications, providing measures for epidemiological studies, and all other activities where some diagnosis is necessary.

* Clinical psychologists, psychiatric social workers, psychiatric nurses, mental health counselors, and
other therapists must use the DSM categories to receive third-party payment for their services. In addition, the manual serves as the benchmark for determining mental disorder in the judicial system. As of 2011, more than 5,500 court opinions cited the DSM. Its diagnoses are invoked in widely disparate legal areas including providing
defense from criminal responsibility, exemptions from the death penalty, eligibility for disability benefits, and determinations in child custody cases.

* The use of DSM diagnoses thus makes it seem as if mental disorders are rampant in the population. Far from being a specialty that treats a small group of seriously disturbed people, psychiatry (and other mental health professions) is charged with a mission to confront a large and growing “public health epidemic” that threatens virtually everyone.

* After the 1960s, however, intense pressures developed from, among other sources, federal regulators, insurance companies, and medical schools to portray psychiatrists as doctors practicing medicine. In recent decades, their legitimacy stems from how they name, define, and distinguish their central concepts from each other: “Diagnosis is the first step in the technological process of transforming a person with an ambiguous complaint into a client with a defined mental disorder.” The credibility of the DSM now depends on its depiction as the evidence-based
result of scientific research. This means that diagnoses must be believed to stem from empirically derived data, despite the evidence justifying many diverse interpretations of symptoms.

* after 1980 [the public] increasingly considered mental disorders something independent of individuals (e.g.,
“have depression”) as opposed to something that is an individual attribute (e.g., “am depressed”).

* Xanax showed the drug industry how valuable the DSM diagnoses could be for marketing their products. It was the first of many successful attempts to commercialize the manual’s conditions. The idea of a tranquilizer that worked across a spectrum of nervous states was dead. “Henceforth,” Edward Shorter observes, “magic bullets would match disease labels: There would be only anxiolytics for anxiety, antidepressants for depression, and antipsychotics
for what everybody was calling ‘schizophrenia.’”

* Ironically, the SSRIs are probably least effective for the condition—depression—that they are marketed for. They are less successful in treating melancholic depression than older medications and have marginal impacts on reactive depression, but they are more effective with anxious conditions.96 Despite this evidence, the need to use the DSM straitjacket led to their initial promotion as “antidepressants.” Whatever the SSRIs do has little
relationship to any specific DSM diagnosis but cuts across many diverse syndromes.

* The diagnostic changes in the DSM-IV allowed drug companies to propel a formerly rare condition to prominence as a widely celebrated cultural phenomenon. Bipolar II exemplifies, as historian Andrea Tone observes, a diagnosis that captures “the relentless expansion of illnesses to accommodate new medications that purport to treat them.”

* Perhaps the most important conclusion emerging from genetic studies was that, contrary to the DSM assumption of disorder specificity, genes for virtually all psychiatric disorders are nonspecific. No disorder corresponds to a distinct gene or group of genes; instead, all share large amounts of genetic vulnerability with other conditions: any genetic variant that is tied to one diagnosis is also associated with multiple others. In addition, the most characteristic symptoms of mental disorders were widely distributed across diagnoses and not localized within any
particular one.

* While medical diagnoses are often uncertain and ambiguous, most diseases are distinct from—not continuous with—health. Even such dimensional conditions as blood pressure or cholesterol levels are divided at cut points that indicate likely pathology. Regardless of whether any illness is dichotomous or continuous in nature, clinicians must make decisions to treat or not to treat it. Therefore, the constraints of medical practice lead physicians, including psychiatrists, to think in black and white. Perhaps most important, diagnostic categories make mental
disorders seem more real to the public, to physicians in other medical specialties, to insurance companies,
and to federal regulators.

* No attempt to develop etiologically informed diagnoses has yet to succeed. “Psychiatry is in the position—that
most of medicine was in 200 years ago—of still having to define most of its disorders by their syndromes,” eminent diagnosticians Robert Kendell and Assen Jablensky observe.

* In psychiatry, however, divorcing symptoms from context has the opposite impact of hopelessly blurring situationally appropriate psychological phenomena from mental disorders. This is because all mental
functions are highly sensitive to environmental circumstances. Virtually every symptom of various mental disorders can sometimes be biologically and psychologically suitable adaptations to given contexts, culturally explicable expressions, or both. For example, symptoms resembling depression that arise after the death of a loved one indicate that grief mechanisms are working appropriately, not inappropriately. Likewise, a panic attack is an understandable response when facing an impending fall off a cliff but a sign of disorder in the absence of danger.
Or hearing voices, which can be a hallmark of schizophrenia, is sometimes explicable in particular cultural and religious settings. In contrast, a heart attack always signals a failure of natural functioning regardless of the context or culture in which it emerges. Unlike other medical specialties, context is an intrinsic aspect of deciding what a mental disorder is or is not.

About Luke Ford

I've written five books (see Amazon.com). My work has been followed by the New York Times, the Los Angeles Times, and 60 Minutes. I teach Alexander Technique in Beverly Hills (Alexander90210.com).
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