By Tom Burns
National Mental Health week in May this year will see the launch of the eagerly anticipated DSM-5. This is the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual which defines all psychiatric diagnoses and is often referred to as ‘the psychiatrists’ bible’. How can something so dry and dull sounding as a classificatory manual generate such fevered excitement? Indeed how did the DSM compete for space in a short book such as the VSI to Psychiatry? Why does it take its place alongside acknowledged classics like Sigmund Freud’s Interpretation of Dreams, or RD Laing’s The Divided Self? The answer is that psychiatry is a practice that is highly sensitive to cultural and social pressures and the origins of the DSM-III, published in 1980, reflected a crisis in psychiatry’s self confidence and is a classic case of unintended consequences.
American psychiatry (which had been dominated by psychoanalysts from about 1940 to 1970) had its prestige seriously dented in the early 1970s. Two major international studies had indicated that they tended to dramatically over-diagnose schizophrenia compared to other developed nations. To make matters worse Rosenham’s famous study ‘being sane in insane places’ was published in 1973. Rosenham got eight volunteers to go to different emergency rooms and say that they were hearing voices that said ‘empty’, ‘hollow’, or ‘thud’ but otherwise to behave absolutely normally. All were admitted to hospital and kept there for several weeks, all were diagnosed with schizophrenia and none had their diagnosis questioned. Clearly this was dire, something had to be done.
DSM-III was the response, a totally new approach to diagnosis. Instead of making a diagnosis by recognising an overall pattern of the illness DSM-III introduced ‘criterion based diagnosis’. So to be diagnosed with a disorder, say depression, the psychiatrist had to identify a core symptom (criterion) of lowered mood for at least two weeks and then four more symptoms (e.g. disturbed sleep, reduced appetite, poor concentration or feelings of worthlessness) out of a list of eight. If you ‘score’ on enough symptoms you have the disorder, if not you don’t. This approach emphasises reliability; the symptoms are simply defined and explained so most doctors will agree on them. It leaves little scope for an overall judgment or deciding on the ‘feel’ of the patient’s presentation. Improving reliability and reducing the variation between different psychiatrists with sharper definitions was meant to reduce the loose over-diagnosis that had plagued US psychiatry up till then. It also should improve the reliability of the drug trials that were coming into prominence.
One should be careful what one hopes for. While the DSM criterion based system has undoubtedly made diagnosis more consistent, it has certainly not made it tighter. As we approach DSM-5 the expansion in this classification is simply staggering. DSM-I in 1952 had 130 pages and 106 diagnoses and has ballooned to DSM-IV in 1994 with 886 pages and 297 diagnoses. The number of individuals who are diagnosed with psychiatric disorders is at an all time high. There is a growing recognition that the DSM system has lead to a medicalisation of everyday life; far too many people with transitory sadness find themselves classified as depressed and prescribed antidepressants. Anxiety disorders such as PTSD and Social Phobia are all too easy to define and hence diagnose, but can they really be as widespread as current practice suggests? Most patients now end up with more than one diagnosis. Even the psychopharmacologists who agitated for DSM-III are now concerned that diagnoses are cast so widely that they undermine, rather than guarantee their trials.
The fact that one can define something and agree on the definition does not make it either real or important. For example, there was good agreement four centuries ago on how to recognise a witch, but that does not mean that these poor women were witches. Similarly having a definition for ‘Oppositional Defiant Disorder’ in adolescents who ‘often argue with adults’ does not make it a psychiatric disorder (any more than nicotine or caffeine dependency which are, believe it or not, listed in there).
Of course we should not be too dismissive about the progress that has been made in reliability and consistency. Psychiatric practice is vastly safer, more predictable and evidence based than ever before. We can hope that DSM-5 will transcend its committee structure and weed out earlier mistakes and sharpen up and refine the range of diagnoses, perhaps deleting those that are hardly ever used. It will certainly not be dull. Since its origins two hundred years ago psychiatry has never been without its controversies and disputes and all the signs are that this is likely to continue.
Tom Burns is Professor of Social Psychiatry at Oxford University and author of Psychiatry: A Very Short Introduction. He has worked as a psychiatrist in Scotland, Sweden, and London before moving to Oxford. He trained as a group analyst and worked as a full time NHS consultant for 10 years before becoming an academic. His research is focused on interpersonal relationships in psychiatry – increasingly relationships with health care staff and the best forms of care for patients with severe illnesses such as psychoses. He has authored over 200 scientific papers and chapters and is the author or co-author of five books. He was awarded a CBE for his services to mental health in 2006.
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