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Post-DSM tristesse: the reception of DSM-5

By Edward Shorter

We’re all suffering from DSM-5 burnout. Nobody really wants to hear anything more about it, so shrill have been the tirades against it, so fuddy-duddy the responses of the psychiatric establishment (“based on the latest science”).

But now the thing’s here, and people have been opening the massive volume — where descriptions of depression are repeated almost verbatim seven times! — and asking what all the shouting was about. Post-DSM-tristesse.

There are a few pluses, and several huge minuses, worth calling attention to, just before everybody goes to sleep again over the question of psychiatric “nosology.” Oh, how the average newspaper reader is turned off by stories on “nosology.”

You have to remember that a lot of smart, well-informed, scientifically up-to-date people were involved in the drafting. So the final result can’t be all horrible.

On the plus side:

The new DSM separates the diagnosis “catatonia” from schizophrenia and makes it a label you can pin on lots of different things, notably depression. Catatonia means movement disorders, such as stereotypes (repetitive movements, common in intellectual disabilities and autism), together with some psychological changes, such as negativism: don’t wanna eat, don’t wanna talk, etc.

Why should anyone care about catatonia? Because it’s treatable. There are effective treatments for it, such as high-dose benzodiazepines and electroconvulsive therapy. If your autistic child has a catatonic symptom such as Self-Injurious Behavior (constantly hitting his head so that he detaches his retinas), he can be effectively treated. This is huge news.

Unfortunately, the pediatric section of the new DSM doesn’t use the term catatonia (apparently it’s only an adult disease) but refers to “stereotypic movement disorder,” without breathing a word about catatonia. But it’s the same thing. This is a real embarrassment for pediatric medicine and it’s a shame that the head disease-designers didn’t take control of the pediatric section as well.

So this is a big plus: Owing to DSM-5, many patients with catatonic symptoms will now be accurately diagnosed and effectively treated. What else? The anxiety disorders section of the DSM has always been something of a dog’s breakfast, heavily politicized and subject to constant horse-trading. But in DSM-5:

Obsessive-compulsive disorder (OCD) is removed from the anxiety section and made a disease of its own. This may encourage the development of new treatments, now that it’s no longer part of the anxiety package. OCD is recognized as responsive to antianxiety meds, but hey, maybe there’s something more specific out there for it. So this would be the way that psychopharmacology progresses — moving together in synch with improvements in diagnosis. It’s the way science is supposed to work.

doctor patient mental health

On the minus side:

In several other key areas, science has not only failed to work, it has been knocked down, kicked bloody, and thrown over the side of the pier.

The core mood diagnoses are still intact: “major depression” and “bipolar disorder.” Major depression is a mix of highly variegated depressive illnesses and should be taken apart.

How about bipolar depressions, involving mania and hypomania? It’s true that they are more serious than garden-variety non-melancholic depressions. But bipolar depressions don’t seem to have different symptoms (different “psychopathology”) than unipolar depressions, even though they may have a more chronic course. And that course doesn’t make them separate diseases. The whole “bipolar” concept is one of those things in science that is true but uninteresting. Yeah, true that some depressions have mania and hypomania tacked onto them. But so what?

Well, there are hundreds of millions of dollars in pharmaceutical profits riding on “bipolar disorder.” That’s what!

“Schizophrenia” is still in there as an undifferentiated entity. Hard to believe, after all this famous “research” that the DSM wonks have been bellowing about, that it remains in the nosology. The old German and French alienists from around 1900 knew there were different forms of chronic psychotic illness. Many of them, especially the French, cast a bleary eye at Emil Kraepelin’s new diagnosis of “dementia praecox” (Eugen Bleuler called it “schizophrenia” in 1908). But the concept was so towering in its majesty — one main psychotic illness with one predictable (downhill) course — that it won out over all the fussy differentiation that other psychiatrists had been attempting. A century of research says that lots of different forms of chronic psychosis exist — all forgotten. Of course the pharmaceutical industry has hyped the single-psychosis-called-schizophrenia line, because antipsychotic agents have been real blockbusters. The money that quetiapine and olanzapine and all the other “second generation” antipsychotics has made is unbelievable.

I could go on but I won’t. You see that the results are mixed, but it’s a tragedy in a way because the results could have been brilliant if: (1) the American Psychiatric Association had not been so determined to ensure continuity from one DSM edition to the next; (2) the patient groups had stopped yowling after their favorite diagnoses; and (3) if Big Pharma had realized that the way to future profits runs through new diagnoses, and only after they are in place, through new drugs.

OK. Now everybody can go back to sleep.

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.

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Image credit: Teenage Girl Visits Female Doctor’s Office Suffering With Depression. © monkeybusinessimages via iStockphoto.

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