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Science Remains a Stranger to Psychiatry’s New Bible

The views expressed are those of the author and are not necessarily those of Scientific American.


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By Ferris Jabr*

Part 2 of a series

In the offices of psychiatrists and psychologists across the country you can find a rather hefty tome called the Diagnostic and Statistical Manual for Mental Disorders (DSM).

The current edition of the DSM, the DSM-IV, is something like a field guide to mental disorders: the book pairs each illness with a checklist of symptoms, just as a naturalist’s guide describes the distinctive physical features of different birds. These lists of symptoms, known as diagnostic criteria, help psychiatrists choose a disorder that most closely matches what they observe in their patients. Every few decades, the American Psychiatric Association (APA) revises the diagnostic criteria and publishes a brand new version of the DSM. The idea is to make the criteria more accurate, drawing on what psychologists and psychiatrists have learned about mental illness since the manual’s last update.

The fat volume on top is still skinny on the science. Courtesy of Ferris Jabr.

In May 2013, the APA plans to publish the fifth and newest edition of the DSM, which it has been preparing for more than 11 years. On its DSM-5 Development website, the APA states that the motivation for the ongoing revisions was an agreement to “expand the scientific basis for psychiatric diagnosis and classification.” The website further states that “over the past two decades, there has been a wealth of new information in neurology, genetics and the behavioral sciences that dramatically expands our understanding of mental illness.”

In other words, the APA intended to make the DSM-5 the most scientific edition of its reference guide yet, which would be a real boon for a book that has been routinely lambasted as fiction borne out of convenience, rather than a solid clinical text grounded in research. Now, only one year away from the planned publication of the DSM-5, most psychiatrists have accepted that the APA’s initial optimism about informing revisions with cutting edge science is well intentioned, but premature. Most of the proposed revisions to current DSM criteria—many of which are genuine improvements—are based not on insights from genetics and neuroscience, but rather on clinical experience, prevalence studies and plain old common sense. Indeed, many of these changes could have been made years ago. (For more on these changes, see “Psychiatry’s ‘Bible’ Gets an Overhaul,” by Ferris Jabr, Scientific American Mind, May/June 2012.)

Cutting and Collapsing Categories

Consider, for example, that the DSM-IV organizes schizophrenia into six types, all of which the APA proposes eliminating from the DSM-5. Why? Because these archaic subcategories were never grounded in empirical research in the first place; they were just what sounded good to the DSM authors of yore. In truth, these ostensible types of schizophrenia probably do not exist. Similarly, the APA is nixing three of the 10 current personality disorders, essentially acknowledging that these were never legitimate illnesses in the first place. So many people fit the criteria for more than one personality disorder simultaneously that 10 varieties become superfluous.

Likewise, the DSM-5 collapses four of the five current pervasive developmental disorders—including autistic disorder and Asperger’s—into a single category called autism spectrum disorders, because there is so much overlap in their respective criteria. None of these revisions are founded on recent revelations from genetics and neuroimaging research. Study after study has failed to discover a set of genes or unusual brain structures that reliably identifies major mental disorders. Rather, these are changes that many psychiatrists have been advocating for the past two decades based on their everyday clinical experience, studies of illness prevalence and the sense that some of the current criteria do not make sense. Despite awareness of these flaws, the APA did not get around to updating the DSM until now, the first substantial revision in 30 years.

One exception to the APA’s disappointed ambitions to base the ongoing revisions on neuroscience are the proposed changes to addictions. Scientists understand quite a bit about how the addicted brain differs from a typical brain. The APA has proposed adding gambling disorder to the DSM-5, in part because reward circuits in the brains of gambling addicts light up in the same way as those in alcoholics and drug addicts. Still, some researchers worry that the DSM will end up sanctioning addictions to everything—gambling, sex, the Internet—shifting focus to what people are addicted to from why addictions form in the first place.

Flaws in the Process

cube decorated with words of despair plus pills

Easing the pain of mental illness requires labeling it. Courtesy of breahn via Flickr.

All the proposed revisions to the DSM-5 emerge from the task force: 27 scientists affiliated with the APA who sort through all the relevant research literature. In the past, many psychiatrists have criticized the APA for not creating an independent review committee to examine this literature—a group of scientists who are not obligated to appease the APA.

In January of this year, David Elkins, president of the Society for Humanistic Psychology, authored an open letter to the APA calling for such independent review: “As you know, it is common practice for scientists and scholars to submit their work to others for independent review…Will you submit the controversial proposals in DSM-5 to an independent group of scientists and scholars with no ties to the DSM-5 Task Force or the American Psychiatric Association for an independent, external review?” [Emphasis theirs]

In a letter of its own, the APA responded: “There is, in fact, no outside organization that has the capacity to replicate the range of expertise that DSM-5 has assembled over the past decade to review diagnostic criteria.”

Recently, the APA has mentioned here and there that it has in fact created such a “scientific review committee,” separate from the task force, but you will not find any satisfactory description of it or its responsibilities on the DSM-5 Development website. Darrel Regier, vice-chair of the Task Force, explained that the committee includes about six scientists selected by the board of trustees, because “there is no way you can have truly independent review,” and declined to say more. Allen Frances, chair of the DSM-IV Task Force and the most outspoken critic of the DSM-5, says that the APA only created this group at the last minute in response to criticisms. “The scientific review committee is not even transparent,” Frances says. “They report confidentially to APA.”

Frances and other critics have pointed to a related flaw in the ongoing revisions. Every time the APA revises the DSM, it conducts “field trials” of new diagnostic criteria. These are dry runs of the proposed revisions in clinical settings that test their reliability—that is, whether two different psychiatrists using the new criteria reach the same conclusion about a given patient.

Since 2010, the APA has been conducting field trials for the proposed DSM-5 diagnostic criteria. (For more on the results of the field trials, click here.) Critics contend—and Regier confirms—that the trials fail to explicitly compare the criteria suggested for the DSM-5 to that in the DSM-IV, except in the case of post-traumatic stress disorder. That is like a taste test in which the judges decide that a new diet soda is better than its non-diet predecessor because everyone approved of the flavor, even though the judges never bothered to directly compare the diet and regular versions. Although in past revisions the APA has done such a comparison, Regier says that this time doing so would double the size of the survey, making it too costly and time-consuming to conduct. “You just don’t do science that way,” Frances says.

*Ferris Jabr is an Associate Editor at Scientific American

Tomorrow: Edward Shorter, a historian of psychiatry at the University of Toronto, argues that the principal diagnoses of the DSM—depression, schizophrenia and bipolar disorder—are artifacts and should essentially be discarded.

Ingrid Wickelgren About the Author: Ingrid Wickelgren is an editor at Scientific American Mind, but this is her personal blog at which, at random intervals, she shares the latest reports, hearsay and speculation on the mind, brain and behavior. Follow on Twitter @iwickelgren.

The views expressed are those of the author and are not necessarily those of Scientific American.





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  1. 1. julianpenrod 12:38 pm 05/8/2012

    Psychology, psychotherapy, psychiatry have always been inherently flawed from a “science” point of view. The various theories of the personality, from Freud to Adler to Skinner to Jung are all fundamentally different. They have absolutely none of the correlation that “science” requires of theories that it deems even partly legitimate. And, while claiming to describe all human behavior, none are based on normal individuals! They all derive from examination of case histories assuming them to be completely accurate representations of all reaction! People without major problems are treated with methods used on the severely mentally deranged! And, yet, those who hold themselves out as “scientists” and defenders of “science” never once criticized the fields! “Science” respects only big money.

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  2. 2. Marai 4:26 pm 05/8/2012

    I am a damned social constructivist and I like this article very much. The more psychiatry (as healing pratice) aspires to be “scientific” (I am not saying it is not based on science), the more it becames disoriented. Talking to someone (communication, language, it can include “talking” in a chemical level by prescribing medicines) is somewhat different from rigorously asking nature by experimenting. There always will be a difference between these two institutionalized practices. Of course I know it is very difficult in this modern era to differenciate between exploitation (of any resources) and healing (which has to be consensual otherwise it won’t happen). They worry too much about standardization, in spite of that effective therapy is more an art than a craft. The motivation is probably not scientific but lies in the nature of American indemnity law and the corporative structure of the profession. I know it is yet much better than in Europe, where they are organized more like a feudal residue…

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  3. 3. jgrosay 6:11 pm 05/8/2012

    Has anybody ever given an acceptable, or at least functional definition of what the heck the psyche is, and what is it for?

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  4. 4. arynix 6:13 pm 05/8/2012

    “In a letter of its own, the APA responded: ‘There is, in fact, no outside organization that has the capacity to replicate the range of expertise that DSM-5 has assembled over the past decade to review diagnostic criteria.’”

    Three problems: 1) How does anyone outside the APA know anything regarding the supposedly vast “range of expertise” of APA members? 2) Can’t anyone-practitioners, researchers, students-access the various studies and journals published by these so-called experts? 3) You’ve never met me. How dare you presume to know my (or anyone else’s) “capacity.”

    As a psychiatric patient myself, I can speak from the inside of this debate. My own M.D.’s office has the words “behavioral health” in its name. Behavioral? Meaning, if I just behaved differently all my problems would go away? Meaning, the drugs that my M.D. prescribes are merely placebos? I don’t think so.

    As long as big-insurance corporatists and their lobbies dominate the “official” definitions of what does, and does not, constitute psychological illness, then they are able to keep afloat the false dichotomy between physical and mental disease or injury, and thereby deny coverage to those whose medical situations are psychiatric (“behavioral”) in nature.

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  5. 5. Travza 6:20 pm 05/8/2012

    @julianpenrod

    You stated:
    “Psychology, psychotherapy, psychiatry have always been inherently flawed from a “science” point of view.”

    I disagree. Freud and Jung’s original assessments were by no means scientific, but we have made strides since in explaining human behavior. That was the whole point of the behaviorist movement Skinner pushed so hard. Both classical and operant conditioning have been empirically confirmed in laboratory settings, and effective treatments for numerous illnesses (such as phobias) have been found as a result.

    You stated:
    “And, while claiming to describe all human behavior, none are based on normal individuals! They all derive from examination of case histories assuming them to be completely accurate representations of all reaction! People without major problems are treated with methods used on the severely mentally deranged!”

    This is just flat out wrong, some of the theories ARE based on normal human behavior. Hell, the most often used theories now are based off of just that! It is true that original studies done by Freud and Young were extrapolations from flawed case studies. There is a reason that the theories of Freud and Young are generally no longer used. Furthermore, Skinner’s models of behaviorism entirely focus on how new behaviors manifest in “normal” people, were derived and confirmed via double blind studies, are continually retested to this day, and apply just as well to normal people as the “severely…deranged”. This is without even talking about Social Psychology, the entire field is devoted to analyzing the behavior of normal human beings and intentionally shies away from the abnormal side of things.

    You said:
    “And, yet, those who hold themselves out as “scientists” and defenders of “science” never once criticized the fields! “Science” respects only big money.”

    Who are you referring to in this passage? It would seem Ingrid Wickelgren is critical of the process. Allen Frances, the chairman of the DSM – IV committee also was critical of how the DSM – V was being handled.

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  6. 6. Maria829 10:34 pm 05/8/2012

    “Consider, for example, that the DSM-IV organizes schizophrenia into six types, all of which the APA proposes eliminating from the DSM-5. Why? Because these archaic subcategories were never grounded in empirical research in the first place; they were just what sounded good to the DSM authors of yore. In truth, these ostensible types of schizophrenia probably do not exist.”

    I think you are correct in stating schizophrenia probably does not exist.

    However, the symptoms of mania, psychosis, visual hallucinations, delusional thoughts, etc. are very real.

    By consensual agreement within the American Psychiatric Association psychiatric diagnoses are descriptive labels only for phenomenology, not etiological or mechanistic explanation for syndromes. Thus, a psychiatric diagnosis labels a pattern of signs and symptoms, but offers no hypothesis concerning the mechanism(s) of the clinical phenomena.(Davidoff et al.,1991).

    The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) classifies psychotic illnesses as “Psychosis Due to General Medical Conditions”, and “Substance Induced Psychosis”. (DSM-IV Codes 293.81 & 292.11).

    Psychosis Due to a Medical Condition involve a surprisingly large number of different medical conditions, some of which are fatal and have been misdiagnosed as schizophrenia/bipolar disorder, others are very treatable conditions.

    A substance-induced psychotic disorder, by definition, is directly caused by the effects of drugs including alcohol, medications, and toxins. Even the routine use of over-the-counter cold medicine can induce psychosis clinically indistinguishable from paranoid schizophrenia.

    Improvements in the diagnostic accuracy and treatment of psychosis is cost-effective for both the mental health consumer and society.

    The science is in the BMJ’s Best Practice Assessment guidelines for psychosis. Clinicians should follow these guidelines:

    http://psychoticdisorders.wordpress.com/bmj-best-practice-assessment-of-psychosis/

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  7. 7. DSArrowsmith 11:48 am 05/10/2012

    English also remains a stranger to the Diagnostic and Statistical Manual of Mental Disorders. The first edition supplanted a pamphlet on hospital record-keeping, but the last time the DSM had any info on statistics was in the second edition of 1968. In the preface to the fourth edition, the editors declared the term “mental disorder” unsatisfactory, but left it in the title because, they said, they couldn’t come up with any more satisfying term. If the APA would change the name of this book to, let’s say, “Diagnostic Manual,” that would signal to users a willingness to shrug off history’s artifacts and attend to the evidence in classifying illness.

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  8. 8. geraldvest 8:49 am 05/29/2012

    How can Psychiatry continue to use the concept and diagnosis–”disorder.” It is so vague, generalized, misused and misrepresented by the mental-behavioral health professions that it would be best to disregard and abandon. Disorder is especially harmful to our “Injured” Warriors who won’t seek help or treatment knowing that the PTSD label sticks on their psyche for life and they will be unemployable when they are medically discharged. See my Petition and sign it to Change Disorder to Injury. http://jerryvestinjuredwarrior.com

    Thank you for introducing the DSM to humanity…it is much like the Bible, especially the Old Testament, as it is a punishing, fear induced and disrespectful system that should be described as pseudo-science and fantasy.

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