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DSM-5 will be the last

By Edward Shorter

In assessing DSM-5, the fog of battle has covered the field. To go by media coverage, everything is wrong with the new DSM, from the way it classifies children with autism to its unremitting expansion of psychiatry into the reach of “normal.” What aspects should we really be concerned about?

Think of a bowl of spaghetti. There are the central swirls of spaghetti in the middle of the bowl and the strands of spaghetti hanging over the side. Most of the controversy has been about the strands dangling down, how we classify marginal disorders of various kinds. It’s not that people with these disorders, such as the hyperactive and the autistic, aren’t important, but they aren’t the meat and drink of psychiatry.

The problem that the DSM-5 doesn’t address lies at the center of the bowl. It concerns psychiatry’s main diagnoses, not its marginal outliers, and those main diagnoses are major depression, bipolar disorder, and schizophrenia. The new edition hasn’t really touched any of them; the way they were defined and classified, and the way they continue to be recognized, ignores major differences within each diagnosis.

Keep in mind how easy it has been to get funny-sounding new diagnoses into psychiatry. Some, such as bipolar disorder, come in as a result of fad. A German psychiatrist named Karl Leonhard created bipolar disorder in 1957 when he said that there are two kinds of depression, unipolar depression (no mania) and the depression that alternates with mania (later called, in DSM-3 in 1980, bipolar disorder). Leonhard’s European and American disciples — a small but influential band — saw to it that separating depressions by “polarity” was widely accepted. Yet there was no new science here; it was the whim of one man.

Some of the diagnoses at the heart of the bowl came in by fiat. Robert Spitzer, the architect of DSM-3, simply decided in 1980 to collapse psychiatry’s various depressions — which had been as diverse as chalk and cheese — into a single disorder: major depression. There were howls of protest, but, hey, the thing was already in print. Set in stone. Even though it makes no scientific sense to classify depressions on the basis of polarity, that’s what we have ended up doing.

Serious depression — or melancholia — remains serious depression whether an episode of mania complicates it or not. Sooner or later, many patients with serious depression will experience some manic features, without that changing their basic diagnosis.

Related to schizophrenia, psychosis (loss of contact with reality via hallucinations or delusions) certainly exists. And there are many forms of it: some come out of the blue, others begin insidiously and seem to grow out of the patient’s personality; some involve loss of brain tissue, others don’t; some end very badly, others stabilize at the ability to lead a more or less normal life: you may not become a neurosurgeon, but you get married, have kids, keep a job, the whole ball of wax. These are different diseases.

St. Elizabeth’s Hospital. Wall of room in Ward Retreat 1. Reproductions made by a patient with dementia praecox…Pictures symbolize events in patient’s past life and represent a mild state of mental regression. Undated, but likely early 20th century. Washington, DC. Selected by Kathleen.

Yet we now give all these forms of psychosis a single diagnosis: schizophrenia. That’s without a plural “s.” If you’ve got chronic psychosis you’ll be called schizophrenic, even though you may not have any symptoms in common with others who have that diagnosis. You may have quite different family (genetic) backgrounds; you may not have a common response to treatment; and you may not have a common course and outcome. Those are all the ways we delineate separate diseases and “schizophrenia” demonstrates none of those hallmarks. It’s an artifact that Emil Kraepelin, the great German disease classifier, inserted into the literature in the 1890s, calling it dementia praecox. So powerful was his concept — that all the different “subtypes” of schizophrenia went remorselessly downhill — that the term has survived the relentless scientific plucking that all other diagnoses in medicine continually experience.

But conceptual power is not the same thing as verification. There is no marker telling us that everybody with “schizophrenia” has the same disease. (There are, by the way, such markers for some other major diseases; I don’t have space to go into it here, but google “dexamethasone suppression test”.)

So, are there problems with DSM-5? Yes, but they aren’t the problems most critics pick at. Criticisms of DSM-5 seem to be rising in a crescendo, as though a gaggle of high-school teachers were called to assess the work of a very naughty schoolboy. The drafters of the current edition were mightily concerned with maintaining stability; they didn’t want to hack great changes into previous editions. So there is not a chance in the world they would have looked critically at these central problems.

But out there in the real world, there are growing numbers of nosological rebels, or skeptics about the DSM version of disease classification. They have mainly stayed off the airwaves up to now. But you can feel the dubiety rising. There probably will not be a DSM-6.

Edward Shorter is Jason A. Hannah Professor in the History of Medicine and Professor of Psychiatry in the Faculty of Medicine, University of Toronto. He is an internationally-recognized historian of psychiatry and the author of numerous books, including How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown,  A Historical Dictionary of Psychiatry and Before Prozac: The Troubled History of Mood Disorders in Psychiatry. Read his previous blog posts.

The OUPblog is running a series of articles on the DSM-5 in anticipation of its launch on 18 May 2013. Stay tuned for views from Daniel and Jason Freeman, Donald W. Black, Michael A. Taylor, and Joel Paris.

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Image credit: By Otis Historical Archives National Museum of Health and Medicine (originally posted to Flickr as Reeve37258). Creative commons license via Wikimedia Commons.

Recent Comments

  1. Richard Parker

    I agree that DSM is mostly a pile of intellectual trash. But bipolarity is valid and the suffering it causes is often substantially relieved by lithium. Anti depressants often worsen its course. When identified this disorder is often treated, dangerously, with atypicals.
    The real issue is informed consent—patients can become as expert as their doctors in a few minutes to days.

  2. Richard Saville-Smith

    Hi, Great blog, nice to see a bit more reason about DSM-5. I wonder if you might be interested in a line I’ve been working on re Dissociative Identity Disorder.

    In the DSM-5 revision “cultural and religious practices” are cited as grounds for non-pathological explanation of disruptive behaviour which might otherwise be treated as a mental disorder. The ramifications of this are significant as it proposes non-biomedical grounds for determining a diagnosis – which is not really what all the noise at the moment seems to have noticed.

    I wrote a paper which I gave to the British Psychological Society’s conference in March.


  3. […] for views from Donald W. Black, Michael A. Taylor, and Joel Paris. Read yesterday’s post “DSM-5 will be the last” by Edward […]

  4. […] of its launch on 18 May 2013. Stay tuned for a view from Joel Paris. Read previous posts: “DSM-5 will be the last” by Edward Shorter, “The classification of mental illness” by Daniel Freeman and Jason […]

  5. […] of articles on the DSM-5 in anticipation of its launch today, 18 May 2013. Read previous posts: “DSM-5 will be the last” by Edward Shorter, “The classification of mental illness” by Daniel Freeman and Jason […]

  6. Anonymous

    It doesn’t matter what name you give it; mental illness is real. All of your condescending, nit-picking, skepticism only serves to create a cloud of doubt in the average person’s mind about whether people who suffer from mental illness are sincere, and whether their doctors are merely pandering to hypochondria. If you actually want to do something helpful, if that is your goal, do some research into the causes and cures for these sufferings instead of doing nothing but criticize those who are trying to work toward naming and understanding them.

  7. Stephen C Pine

    I for one, have been “diagnosed” with several mental health related disorders. Reluctantly, I do not feel that all psychological and psychiatry medical professionals have a complete understanding of “real life” encounters that create the diagnosis of mental health disorders, because they themselves have not / were not subjected to domestic violence as a child and as an adult. Military career during the Persian Gulf war, aided in some of the disorders diagnosed. I live a normal every day life. However, the contrary, there are 4 medical professionals in the realm of psychiatry & psychology, that have the same diagnoses, and three that are the contrary. I as a parent well diverse with the DSM-V am hesitant to think that any written test administered, or consultation will give any person a proper accurate diagnosis. It’s the bureaucratic / political / governmental people that need the understanding and teachings of “real life” events that cause mental health disorders unless significantly born with a developmental disorder in plain sight by the age of infancy to three years. I’d love the opportunity to meet with professor Edward Shorter at the University of Toronto to get his take on any inside mental health disorder(s) I am being told I have, by all medical “professionals” that are contrary to eachother. Also my son now 10yrs old was diagnosed by age 6 was Diagnosed with Autism mild (level 1). To the contrary 4 psychology professionals say that my son has “emotional distubance”, gee; emotional disturbance is a characteristic & trait of Autism. 5 other medical professionals say my son has Autism, contrary to 3 other medical professionals. Come on, get it together in the world of psychiatry & psychology.

  8. David Franklin

    Bipolar is not valid. Oh, there are certain genetic variants that often correlate with severe mood disturbances and sleep disturbances that mess people’s lives up. That’s it, according to clinical psychiatry.
    Research psychiatry has turned up quite a bit of knowledge – but clinical psychiatrists deny its existence, and get angry with patients who tell them about it.
    Despite a stack of good research, clinical psychiatry advances no explanation of etiology, mechanisms, structural or biochemical abnormalities, and continues to insist that bipolar is incurable.
    The only proofs that bipolar is incurable are psychiatrists’ insistence, and the demonstrated fact that most people who come off meds develop severe dysfunction again.
    But when research has clearly shown that “bipolar brains” show thinning of cortical grey matter visible on scans, and research has also clearly shown that most psychiatric meds cause thinning of cortical grey matter – I am not surprised that bipolar can’t be cured by meds. They’re making things worse!
    Or possibly, they’re confusing the effect of the meds with the effect of the disease/disorder. This rather makes me wonder if the research is actually that good.
    Lithium isn’t so bad. It only causes chronic kidney failure in a third of patients. Wonderful.
    BDNF has been found to be low in mentally ill brains, and eating turmeric boosts BDNF, so why aren’t patients being told to eat curries? Are psychiatrists worried that people will think they’re cRAzYY? Shock, horror! That cannot be allowed!
    The plain fact that diseases of the brain are plainly the province of neurologists, or physiologists, or biochemists, and that the entire speciality of psychiatry is pointless needs to be raised and reiterated until a speciality that is looking for an excuse to exist is abolished.
    And no, I’m not just a bitter patient. I was, for ten years. Now, I forgive you, and I look elsewhere for answers. I was trained as a biologist, and if there is something wrong with my biological body that biologically-based medicine has researched, but a moribund “medical” field refuses to acknowledge – I refuse to acknowledge it.
    If zoologists claimed to know nothing of the habitat, behaviour, and numbers of a species decades after discovering it, people would be forced to conclude that the species was extinct, had not been researched, or never existed in the first place. The thought that it had been researched extensively, but the people sounding off about it had never read the research papers would probably not even occur to most people. That some might well know the truth about the species, and lie for personal gain, that does occur.

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