I was heavily involved in the third and fourth editions of the manual but have reluctantly concluded that the association should lose its nearly century-old monopoly on defining mental illness. Times have changed, the role of psychiatric diagnosis has changed, and the association has changed. It is no longer capable of being sole fiduciary of a task that has become so consequential to public health and public policy.
Psychiatric diagnosis was a professional embarrassment and cultural backwater until D.S.M.-3 was published in 1980. Before that, it was heavily influenced by psychoanalysis, psychiatrists could rarely agree on diagnoses and nobody much cared anyway.
D.S.M.-3 stirred great professional and public excitement by providing specific criteria for each disorder. Having everyone work from the same playbook facilitated treatment planning and revolutionized research in psychiatry and neuroscience.
Surprisingly, D.S.M.-3 also caught on with the general public and became a runaway best seller, with more than a million copies sold, many more than were needed for professional use. Psychiatric diagnosis crossed over from the consulting room to the cocktail party. People who previously chatted about the meaning of their latest dreams began to ponder where they best fit among D.S.M.’s intriguing categories.
The fourth edition of the manual, released in 1994, tried to contain the diagnostic inflation that followed earlier editions. It succeeded on the adult side, but failed to anticipate or control the faddish over-diagnosis of autism, attention deficit disorders and bipolar disorder in children that has since occurred.
Indeed, the D.S.M. is the victim of its own success and is accorded the authority of a bible in areas well beyond its competence. It has become the arbiter of who is ill and who is not — and often the primary determinant of treatment decisions, insurance eligibility, disability payments and who gets special school services. D.S.M. drives the direction of research and the approval of new drugs. It is widely used (and misused) in the courts.
Until now, the American Psychiatric Association seemed the entity best equipped to monitor the diagnostic system. Unfortunately, this is no longer true. D.S.M.-5 promises to be a disaster — even after the changes approved this week, it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription. The association has been largely deaf to the widespread criticism of D.S.M.-5, stubbornly refusing to subject the proposals to independent scientific review.
Many critics assume unfairly that D.S.M.-5 is shilling for drug companies. This is not true. The mistakes are rather the result of an intellectual conflict of interest; experts always overvalue their pet area and want to expand its purview, until the point that everyday problems come to be mislabeled as mental disorders. Arrogance, secretiveness, passive governance and administrative disorganization have also played a role.
There were a couple things I thought this this piece did a good job of illustrating. First, that the history of the DSM wasn't Allah speaking directly to his prophet who then immortally inscribed these truths into the first issue of the DSM, but that it was largely just an attempt to assemble what most people thought about things out of the primordial ooze that was mainstream psychology as recently as a few decades ago. Second, that despite these somewhat inauspicious origins, most people believe the word of the DSM like it is the bible, including decisionmakers like courts and legislatures. Third, that there will never be a perfect DSM because of fundamental disagreements and the accompanying political machinations amongst the experts that write it. So, in a word, the DSM is not the most reliable system in the world.
Consumers should play an important role in the review process, and field testing should occur in real life settings, not just academic centers.Psychiatric diagnosis is simply too important to be left exclusively in the hands of psychiatrists. They will always be an essential part of the mix but should no longer be permitted to call all the shots.