Carlos R. Hojaij: “DSM-5: The Future of Psychiatric Diagnosis”or Continuing the Psychiatry DiSMantlement*
“The 5th Edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in May 2013 marks one of the most anticipated events in the mental health field.”
With this pompous sentence the American Psychiatric Association promotes the new edition of its best-seller. DSM propitiates a fabulous financial profit while instilling into the psychiatric diagnosis process an excessive bureaucracy; DiSMantles psychiatry and sucks dry its richness and mystery; and makes the patient subject to too many different tags without a scientific (psychopathological/nosological) meaning.
After so many years, there remain serious doubts about whether the DSMs have brought any positive contribution to Psychiatry, in the sense of a really scientific and practical classification, objectively facilitating psychiatric activity and benefiting patients. The arrogant promotion of bureaucracy and quick creation of a classification, and the establishment of a Psychiatry to overcome the traditional European psychiatry founded in several centennial schools, gave space for the communitarian strategy of consulting many and different social and professional sectors: “medical groups, advocacy organizations, individuals who work in mental health settings, and most certainly patients and family members” as David Kupfer, DSM-5 Task Force Chair wrote in Medscape in June 1, 2012. Nearly 12,000 inputs were received from 2010 to the beginning of 2012!
It is simple to observe that this huge field, open to contributions of so different origins, brings serious problems:
1 anonymity -- no one can be taken as responsible;
2 superficiality and imprecise data;
3 bias due to particular interests of people, groups, institutions, companies, etc., many times disconnected from the supposed main objective;
4 and final results submitted under pressure coming from the so many different participants, which understandably want their data or opinion to prevail.
The second part of this immense fragmentation continues in the several task forces. The task forces are also composed of several members. Debates, disputes and decisions are developed under the communitarian spirit: compromise to satisfy the various and many conflictive interests. (As some members will not be satisfied with the results, probably the combat is suspended until the next revision.) There is not a coherent unity to the structure of the so-called mental disorders. The DSM looks like a surrealist mosaic.
It should be then asked: “Is this science? Does this add knowledge to the progress of psychiatry? Is the patient the center of everything still?”
This new edition (innovated by the Arabic digit “5,” instead of the Roman digit “V”) is intended to establish connections between psychopathological data and biological markers, and specifications of biological tests aimed at the identification of clinical entities. It failed, since until now there is no biological element that could be related to a psychiatric clinical entity (we are here considering the grand group of endogenous psychosis), and there is not any test (genetic or imaging) that could guarantee an entity's identification. It failed because the current knowledge about the brain is still in puberty. It failed - even more - for having regretfully abandoned Psychopathology and replacing it with simplistic quantitative scales to ease statistical data manipulation. Ignoring the patient and the complex general and individual symptomatology are the worst consequences. It failed because the technological progress propitiating advances in epidemiology, pathophysiology, genetics, pharmacology, neuroscience, etc., were not properly integrated into psychopathological research. The most horrendous example is the “creation” of “Schizophrenia Spectrum and Other Psychotic Disorders.” If before to characterize Schizophrenia as an entity was problematic, now the problem is solved by the putting of all psychoses in just one basket, this way eliminating the exhaustive phase of the forgotten differential diagnosis. It is easy to treat!
In relation to psychoses, this new-born edition gave birth to the so-called “Attenuated Psychosis Syndrome” (APS). Through this creation, the diagnosis would be applied to persons with “psychotic sub-symptoms” that cannot yet be characterized as psychotic symptoms!!! This black pearl will identify “patients to be:” persons under risk of an evolution to a kind of “psychotic disorder.” Obviously and inevitably, this absurdity will cause millions of people to be submitted to a discriminatory and unnecessary use of anti-psychotics. In a recent article, Brandon Gaudiano and Mark Zimmerman (2012) concluded: “We could not identify any patient who clearly could meet criteria for APS alone in our sample (1,257 individuals recruited from June 1997 to June 2002). Psychotic experiences appear to be common in outpatients and represent nonspecific indicators of psychopathology. Diagnosing APS in the community could result in high rates of false positives or high rates of APS ‘comorbidity' with other non psychotic disorders.”
The Psychiatry DiSMantlement is processed through the “creation” of numerous “disorders,” essentially based on symptoms. In reality, it is a kind of symptom descriptive classification, far away from the searching for establishment of clinical entities with a defined biological basis. However, the more striking is the constant distancing from the traditional syndromes with a potential for a specific entity (Schizophrenia, for instance). By adopting DSM, Psychiatry discarded the ideal of a nosological entity, just touched the syndromes, and was reduced over the precarious and ridiculous identification of unspecific symptoms. Examples: Disinhibited Social Engagement Disorder, Caffeine Use Disorder, Internet Use Disorder, Disruptive Mood Dysregulation Disorder, Social Communication Disorder, Hoarding Disorder, Skin Picking Disorder, Callous and Unemotional Specifier for Conduct Disorder. The following “categories” may be subject to comments marginal to serious: Female Sexual Interest/Arousal Disorder, Male Hypoactive Sexual Desire Disorder, Genetic-Pelvic Pain/Penetration Disorder. Could all of these “categories” be part of a psychiatric classification?
Beside this annihilation of Psychiatry as a medical science, there is an uncharacteristic language, socialized, popularized, completely distant from the phenomenological psychopathological description. DSM builds up a language concerning popular judgement, maybe to facilitate prescriptions of drugs to those approaching psychiatrists already having made up their minds about diagnosis and pharmacotherapy. It is more simple, rapid and easy to be identified with a symptom instead of going into a medical process for a proper investigation.
Although being DSM-IV Chair, Allan Francis became very critical of number 5. (I wonder why now he is taking this position, for in my understanding, since 1973 all DSM present the same gross defects.) He talks about “reckless suggestions that now appear fast-tracked to make it into DSM-5.” Some of them are: Disruptive Mood Dysregulation Disorder; Minor Neurocognitive Disorder; Lowered ADHD Threshold (by rising the allowed age of onset to 12); and a category for “behavioral addictions” that will promote “Internet Addiction” as a NOS diagnosis. Can addiction to sex, shopping and work, etc., be far behind? Making binge-eating a mental disorder?
Atomically pulverizing the patients with the consequent escalation in the number of “mental disorders,” DSM also increases the number of stamped persons (psychiatrically stigmatised people) and, consequently, the number of persons under prescriptions (new patients). In this regard, Francis mentions issues that arose after the publication of the DSM-IV: the diagnosis of Autism increased 20-fold; children with bipolar disorder also increased 20-fold; the number of people diagnosed with ADHD tripled; and the cases of Bipolar Disorder doubled (looking around, it seems that this number is much much higher, for nowadays there is kind of a world epidemic Bipolar Disorder and a substantial increase in sales of anti-psychotics and mood stabilizers).
Maybe the best designation for DSM would be “mixed salad,” with high water rate and very low substance. This salad is causing Psychiatry to suffer a mental anorexia. For Francis, it seems this salad is not very attractive: “I would bet my house that none of the DSM-5 changes would ever make it through an impartial and rigorous scientific review.” (In “What's wrong with DSM-5?” interview with Medscape, January 2012). (It is a pity Francis did not have this same critical spirit at the time he was the DSM-IV Chair!)
“Representing 36,000 physician leaders in mental health,” DSM is not a scientific work. It is not possible to have a scientific project with 36,000 collaborators, even if all of them are highly distinguishable (which per se would be impossible). DSM is just an “interest accommodation box,” where Psychiatry is not present.
Hopefully this demagogic, populistic, communitarian and noncritical DSM expansion will collapse one day, much before the last Psychiatrist sentinel.
American Psychiatric Association. Dianosticand Statistical Manual. Fifth Edition (DSM-5). Washington: American Psychiatric Association; 2013.
Francis A. Whither DSM-V? Br J Psychiatry 2009; 195: 391-2.
Gaudino B, Zimmerman M. Prevalence of attenuated psychotic symptoms and their relationship with DSM-IV diagnosis in a general psychiatric outpatient clinic. J Clin Psychiatry. 2013 Feb;74(2):149-55.
*Adopted from an essay posted in October 2012 on the website of the Brazilian Association of Biological Psychiatry, which is no longer in operation.
Carlos R. Hojaij
December 22, 2016