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1984 Revisited: The New DSM

November 30, 2011

Which of us is crazy and who isn’t and why? These are the questions that psychiatrists and the rest of us have been trying to answer since the late 18th century and the advent of moral treatment, when mad men and women were unchained and treated as human beings. One hundred years later, Emil Kraepelin actually drew a line demarcating one group from the other: on the one side, were those individuals who experienced hallucinations, delusions; were affectively dysregulated; and cognitively disorganized, i.e., had disturbed speech and attention deficits. On the other side of the line was everybody else, i.e., those whose behavior was normative.

Kraepelin went on to postulate that persons who were mad were mentally ill, were suffering from a neurophysiological pathology; that the symptoms they exhibited were attributable to or caused by the fundamental pathology, and that the pathology itself could be further sub-divided into a system of classifications or nosology. He identified three: dementia praecox, which Bleuler later re-classified as schizophrenia; manic depression, which included both bi-polar and unipolar deprression; and the paranoias. Karl Jaspers, a younger contemporary, later added what amounted to the personality disorders and anxiety-related disorders.

These are the schemata under which Western psychiatry has operated ever since, with some notable exceptions largely driven by class differences among their patients. For example, here in the U.S., American psychiatrists, indeed all mental health professionals, were trained in Freudian psychoanalysis. Nonetheless, poor persons and persons of color were those most likely to be confined in large state institutions where Kraepelinian principles governed and, much like today, were rarely afforded psychotherapy as a treatment option; persons of means were largely treated in outpatient settings by therapists trained in psychodynamic approaches. All this came to an abrupt end with the publication of the DSM-III in 1980. Freud and psychoanalytic conceptions of mental disorders were out and Kraepilinian concepts—or as per Gerald Klerman’s triumphalist notion, neo-Kraepelinian—were in.

DSM-III had multiple objectives, some clinical, some political. Primarily, evidence was to be gathered through extensive field trials to demonstrate that mental disorders were true medical illnesses, of neuro-biological origin, best treated by medical means, i.e., psychoactive medications. The validity of the diagnoses presented—DSM-III classified 163 distinct diagnoses, up from DSM-II’s 137 (1968) and DSM-I’s 94 (1952)—i.e., their construct validity, would then no longer be open to question. Further, the inter-rater reliability, i.e., the extent to which clinicians and researchers, particularly the latter, could agree on a diagnosis, would be significantly improved.

In sum, psychiatrists, having demonstrated that they treated bona fide illnesses, would unquestionably be seen as bona fide members of the medical profession, distinct and apart from all other mental health professions, and would have to be regarded as such by their peers as well as by the insurance companies that paid their fees. Their status as physicians would also guarantee them clinical deference from other mental health professionals and their statutory capacity to write prescriptions would install them as gatekeepers to the mental health system and pre-eminent collaborators of the pharmaceutical industry. In sum, psychiatrists’ leadership of the mental health system would be unchallenged.

Kirk and Kutchins (1992) and, later, Bentall (2003) wrote precise analyses of DSM-III’s shortcomings, rebutting all the foregoing claims its authors had made for it. Pointedly, Kirk and Kutchins entitled their book The Selling of DSM: The Rhetoric of Science in Psychiatry. They point out that construct validity is never addressed in the DSM-III; Bentall chimes in to say that it wasn’t addressed in IIIR or IV, as well. The highly ballyhooed field trials show no direct connections between specific diagnosis or presumed illness, etiology, symptoms unique to that diagnosis, treatment unique to the diagnosis and prognosis or anticipated outcome.

Furthermore, the attention focused on reliability obscures that fact. In short, no diagnosis has a proven construct validity, i.e., has no basis in empirical data, is, to be blunt, a construct of the authors’ collective imaginations. To compromise the DSM even more, inter-rater or –clinician reliability is barely supported by the data aggregated in the field trials.

As per Kirk and Kutchins, DSM’s authors decided to make use of the kappa statistic, a mathematical formula often utilized in social sciences research—e.g., anthropology, sociology—to minimize reliability occasioned by sheer chance. High reliability would be signified by a kappa score of .7. In the DSM-III reliability field trials, no Axis I or II diagnosis achieved the .7 score—the data analysis came close but never got there. The follow-up field trials for DSM-IIIR and –IV scored low in reliability particularly as regards personality disorders and disorders of childhood and adolescence.

Interestingly, no alarms were raised, no protests made that the DSM authors’ claims for construct validity and reliability were never realized. Kirk and Kutchins’ explanation is that psychiatrists and other clinicians bought the rhetoric; further, the effective propaganda campaigns undertaken by the insurance and pharmaceutical industries completed the tautology—the unquestioning reliance of those industries on the DSM were proof of its reliability. Similarly, construct validity was no longer an issue because the medications, prescribed to treat biomedical illnesses, worked. Didn’t they?

When I first read Kirk and Kutchins’s and Bentall’s accounts of the DSMs, I was struck by the fact that each succeeding edition moved Kraepelin’s line demarcating the ill from the not-ill to include more of the former. DSM-III R, published in 1987, included 174 diagnoses, up from III’s 163; less than 10 years later, DSM-IV, issued in 1994, had 201 diagnoses; IV TR, 2001, had over 250 diagnoses. One of the key criticisms directed at DSM-V, now projected to be published in 2013, three years later than its original release date, is that it has lowered the threshold for mental illness, leading to expectations that the number of newly conceptualized diagnoses will surely grow.

An analysis of the DSM-V conducted by the Society of Humanistic Psychology of the American Psychological Association and contained in an “Open Letter to the DSM-5 (Task Force),” draws attention to several diagnoses—e.g., Attenuated Psychosis Syndrome and Disruptive Mood Dysregulation Disorder—largely aimed at children and adolescents, which, the APA contends, have little support in the clinical research literature and which undoubtedly will result in treatment with neuroleptic or other psychoactive medications. Similarly, the APA raises concerns about the re-classification of Attention Deficit/Hyperactivity Disorder to “Neurodevelopmental Disorders,” which will now give it a clear “neurological basis”, result in the “medicalization as well as the over-diagnosis of this disorder” and the depreciation of the importance of socio-cultural factors. The “Letter” also describes the DSM-V’s re-definition of “a mental disorder (as) a behavioral or psychological syndrome or pattern that is not primarily a result of social deviance or conflicts with society.” The APA’s expressed concern is that the new definition now “fails to explicitly state that deviant behavior and primary conflicts between the individual and society are not mental disorders.”

The APA summarizes its concerns in the following: that “the proposal to lower diagnostic thresholds is scientifically premature and holds numerous risks … (that) increasing the number of people who qualify for a diagnosis may lead to excessive medicalization” and increased prescription of neuroleptic medications with all their attendant risks. Unstated but implied are the beliefs voiced nearly 10 years ago by Loren Mosher in the book of readings he co-edited with John Read and Richard Bentall in 2004, just before he died: that psychiatry has sold its soul to Big Pharma; that neither the biomedical model in which modern psychiatry is rooted nor the nosology of mental illness publicized via its series of DSMs has an empirical basis; and that environmental factors at the heart of psychotic experiences, particularly childhood abuse and resulting trauma, have been systematically ignored. When I first read the APA’s open letter, my first thought was Orwell and 1984, his increasingly prescient novel published in 1949, over 60 years ago. He envisioned a world whose “citizens," the 99 percent , would be drugged on soma, a presumed narcotic that rendered people emotionally numb and submissive to “Big Brother”, their unknowable protector who safeguarded them from an unknowable enemy. I couldn’t help thinking that this was indeed the possible endpoint that the DSM and its authors, the ivory tower researchers and psychopharmacologists, together with Big Pharma, might bring us to.

I was also reminded of Thomas Szasz and his belief that mental illnesses were myths whose function is to justify control of individuals who are a nuisance to others. As Bentall reminds us, Szazs has never considered himself as “anti-psychiatry,” but rather sees “mental illness” as an incoherent concept, with no evidence ever presented of its existence as a physical pathology. I’ve always been sympathetic to the notion that that the social welfare system, including the mental health system, function as mechanisms of social control. Many years ago, when I was a brand new social worker working as a child welfare worker in the LA County Department of Public Social Services, in the late 1960s, at the height of the anti-war movement, my fellow workers and I referred to ourselves as “cops in mufti.”

Given the racism inherent in mental health and the wholesale discrimination directed at the system’s survivors, who are principally poor and persons of color, I can’t disagree with the notion that the mental health system exists largely to control and marginalize poor people. Just remember that, in the early 1950’s, when the DSM-I was published, psychiatry decided that homosexuality was a mental illness. Twenty years later, psychiatrists took a vote at their annual convention and decided that homosexuality was no longer a mental illness. Was new clinical evidence submitted to support that change or did the gay community simply organize and muster the political muscle to protect their rights as bona fide citizens.

So, if the psychologists are correct and the biomedical model of mental illness is to be discarded or substantially revised; if, similarly, the DSM itself is to be discarded or substantially revised as they are requesting in the “Open Letter”, what are we, both practitioners and survivors, to be left with? Well, several of my blogs were devoted to advocating the replacement of the biomedical model with a trauma model connected in some manner, consequent to additional research, to the ACES study. Interestingly, John Read and colleagues recently reviewed studies demonstrating a clearer link between early childhood trauma and the origins of schizophrenia or severe psychosis. Specifically, from two-thirds to 85 percent of all women hospitalized in acute psychiatric units were found to be victims of childhood sexual and/or physical assault and/or of emotional abuse or neglect. Surprisingly, 60 percent of all hospitalized men had been similarly victimized.

Bentall’s alternative is more systematic. He begins with what he terms the “principle of continuity,” which suggests that madness or psychosis is but one end of a continuum of human experience, with presumed normative social functioning anchoring the other. To illustrate this notion, he cites several relatively recent studies that examine key Schneiderian first-rank positive schizophrenic symptoms—or, as Bental terms them, “complaints”: hallucinations, delusions and cognitive disorganization, particularly incoherent speech. He begins with John Tien’s study, published in 1991, wherein Tien, an American psychiatrist, reported that ten percent of 18,000 randomly selected individuals, with no psychiatric histories and drawn from disparate locales across the U.S., had experienced auditory hallucinations at least once during the course of their lifetimes.

Similar results were obtained in a study published by Jim van Os in 2000 involving 7,000 persons in Holland, as well as in a study published that same year of 700 persons living in Dunedin, New Zealand. Since the incidence of persons diagnosed with schizophrenia in these three countries is about 1 percent, it would appear that, at least in the three studies, ten times that number reported hearing voices. Bentall proceeds to cite Newman’s and Baumeister’s 1996 report that nearly four million, never-hospitalized Americans earlier in that decade had claimed to have been abducted by aliens and then returned, unharmed, to their homes. He concludes with Andreasen’s and colleagues’ 1995 article that disordered speech is more likely to be encountered in persons suffering from non-psychotic depression than in those persons diagnosed with schizophrenia.

So why weren’t any of these folks hospitalized? I guess they didn’t offend or get noticed by the right people.

As for treatment, Bentall doesn’t advocate junking the bio-psycho-social model, but does believe it needs to be re-balanced. As Read and colleagues have argued, the biological aspect of this model has “colonized” the other two, rendering them ignored and meaningless. Since no biologically-based etiology for psychosis has been established, biology and biological treatment, viz., psychoactive medications, should be assigned adjunctive roles in what the APA in its “Open Letter” terms the “psychiatric taxonomy” or system of classification.

Greater prominence needs to be accorded the psycho-social nature of individuals’ symptoms or “complaints” and their psychotic experiences. As per Bentall, research is continuing to identify hallucinations and delusions as psychological complaints, i.e., products of individuals’ minds that affect their behaviors; and their origins are to be found in individuals’ environment, i.e., the socio-cultural context in which they live.

Accordingly, Bentall proposes a “complaints-oriented” treatment approach, where psychotherapists assist persons experiencing the complaints to explore them, validate/accept their existence, and learn skills necessary to cope with/manage their complaints and so live life to the fullest. As per Bentall, if the complaints are successfully treated, only the “ghosts” or faint memories of their presumed illnesses will remain and there will longer be need for diagnoses.

Specifically, he recommends two research-validated treatment interventions: cognitive-behavioral therapy and “need-adapted” family therapy. The latter, which centers around a psychosis treatment team comprised of therapists, the person experiencing the psychosis, and her/his family members, is home-based rather than hospital- or clinic-based, and is the treatment of choice used throughout Finland and other Scandinavian countries for individuals experiencing their first psychotic episode.

Results over the past 40 years, when the Finns began developing this model, have been uniformly good. A two-year outcome study published in 2001 showed nearly half of study participants to be working two-years post-discharge. The sparing use of neuroleptics with these persons also highlights its preventative/prophylactic character.

To which I would add DBT and its Group Skills Training, which I always found useful in ameliorating the painful feelings that torment its participants; and the group support provided by peer-run programs. Who else but fellow survivors will know what you’re going through and won’t judge you for it?

In the interim, what are we to do? The American Psychological Association, which has joined forces with the American Counselling Association and the British Psychological Society in requesting that the DSM-V Task Force allow a broader review of its work to date by other mental health professionals, is correct in asserting that the bumbling performance of the Task Force presents those of us who are dismayed by the current disarray of the public mental health system in this country an unprecedented opportunity to change things—to bring psychiatry back from its delusions of grandeur and to curb the excesses of Big Pharma and the insurance industry.

Big targets with lots of power and money, but vulnerable because of the harm they’re doing to so many. We can begin by signing the petition that the APA has been circulating and which can be accessed at http://www.ipetitions.com/petition/dsm5/?utm_medium=email&utm_source=system&utm_campaign=Send%2Bto%2BFriend

Please note that the “Open Letter to the DSM-5” is also found there and serves as both explanation of and preamble to the petition.

To date, nearly 8,000 mental health professionals and their organizations have signed the petition. Even Allen Frances, the editor/co-editor along with Bob Spitzer of DSM-III, -IIIR, -IV and IV TR, has urged his fellow psychiatrists to sign. To quote him: “But what is the most compelling reason for signing the petition to reform DSM-5? This is easy. Our first responsibility is to DO NO HARM!!! (Caps and exclamations Allen’s not mine.) DSM-5 will do grave harm to the people who are misdiagnosed and often receive unnecessary medication …”

Frankly, I haven’t been able to locate the metropolitan NYC and national chapters of NASW or the Nurses’ Association as petition signatories. Maybe I haven’t looked hard enough, or maybe most other mental health professionals and our professional organizations, unlike our psychologist brothers and sisters, have simply accepted DSM-5 as a fait accompli. I’ve recently contacted the NYC Chapter of NASW, which is awaiting publication of this blog. You have to start somewhere. I invite those of you who are reading this and feel similarly compelled to do likewise. T

hose of you who wish to discuss this further, feel free to contact me at jacarneysr@aol.com.

Remember … don’t mourn, organize!

References

  1. Allen, F., “Why Psychiatrists Should Sign the Petition to Reform DSM-5,” Psychiatric Times, November 4, 2011
  2. Andreasen, N., et al, “Positive and Negative Symptoms,” in Hirsch & Weinberger, eds., Schizophrenia, Oxford U. Press, 1995
  3. Bentall, R., Madness Explained: Psychosis and Human Nature, Penguin Books, London, 2004
  4. Bentall, R., “Abandoning the concept of Schizophrenia: the cognitive psychology of hallucinations and delusions,” in Read, J., Mosher, L.R., Bentall, R., eds., Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia, Routledge, London & New York, 2004
  5. Carney, J., “Helping Consumers Add Years To Their Lives, V: Replacing the Disease/Biological Model with ACEs”, Behavioral Healthcare, www.behavioral.net, May 3, 2011
  6. Carney, J., “Helping Consumers Add Years To Their Lives, VI: The Implications of ACEs and a Trauma-based Treatment Model”, Behavioral Healthcare, www.behavioral.net, May 18, 2011
  7. Carney, J., “Helping Consumers Add Years To Their Lives, VII: More Implications for Treatment & Training”, Behavioral Healthcare, www.behavioral.net, June 3, 2011
  8. Foucault, M., History of Madness, Routledge Press, New York, 2006 (1961)
  9. Kirk, S.A., Kutchins, H., The Selling of DSM: The Rhetoric of Science in Psychiatry, Aldine de Gruyter, New York, 1992
  10. Klerman, G.L., “The evolution of scientific nosology,” in Shershow, J.C., ed., Schizophrenia: Science and Practice, Harvard U. Press, Cambridge, Mass., 1978
  11. Mosher, L.R., et al, “Drug Companies and Schizophrenia: unbridled capitalism meets madness”; & “Non-hospital, non-drug intervention with first-episode psychosis,” in
    Read, J., Mosher, L.R., Bentall, R., eds., Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia, Routledge, London & New York, 2004
  12. Newman, L.S. & Baumeister, R.F., “Towards an Explanation of the UFO Abduction Phenomena: hypomanic elaboration, extraterrestrial sadomasochism, and spurious memories,” Psychological Inquiry, 1996, vol. 7, pp. 99-126
  13. Read, J., et al, “Childhood Trauma, Loss and Stress,” in Read, J., Mosher, L.R., Bentall, R., eds., Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia, Routledge, London & New York, 2004
  14. Society for Humanistic Psychology, “Open Letter to the DSM-5,” http:www.ipetitions.com/petition/dsm5/
  15. Tien, A.Y., “Distribution of hallucinations in the population,” Social Psychiatry and Psychiatric Epidemiology, 1991, vol. 26, pp. 287-92
  16. van Os, J., et al, “Strauss (1969) revisited: a psychosis continuum in the normal population?”, Schizophrenia Research, 2000, vol. 45, pp. 11-20
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