Edward Shorter's Comments


Carlos R. Hojaij: DSM-5:
The Future of Psychiatric Diagnosis or Continuing the Psychiatry DiSMantlement



            To Dr. Hojaij's stimulating essay one can only say "Amen"!  We have been sold a terrible bill of goods with the DSM system.  It had the advantage in 1980 of bringing psychoanalysis in psychiatry to the beginning of the end.  But it had no other advantages, and now, in the great hiatus of drug discovery, and in the feeling of many psychiatrists that the DSM diagnoses do not well describe their patients, we are paying the price of an ill-considered and highly politicized system of diagnosis.

            Dr. Hojaij makes several excellent critical points:

1.  He notes the incoherence of too many voices included at the time of drafting.  We don't decide science by widespread polling.  The patients do not have a seat at the nosology table, however sympathetic we may be to their complaints.

2.  He is scandalized by the horsetrading of the Task Force system:  I'll give you your diagnosis, if you give me mine.  We don't decide science through negotiation.  The speed of light was not settled in a committee.

3.  Dr. Hojaij correctly notes that the designers' aspiration to re-cast DSM-5 with the aid of biological markers failed completely.  Yet let's not throw the baby out with the bathwater.  There are biological markers in psychiatry, such as the Dexamethasone Suppression Test (DST) and REM latency, which stand us in good stead in differentiating out melancholic depression.  Yet none of the DSM Task Forces have paid them any attention.  The endless repetition of the mantra, "There are no biological markers in psychiatry" has not served us well.

4.  Dr. Hojaij is aghast at the perpetuation of such artifacts as "schizophrenia."  And he's right: There is no single disease called "schizophrenia"!  Many perceptive observers have made this point over the last half century.  Yet schizophrenia, like a blind and crippled drunk, staggers on.  When will this 100-year-old relic finally be sent for re-hab?

5.  Perhaps Dr. Hojaij's most trenchant critique is that DSM-5 worsens the tendency to make symptoms into "disorders," e.g., "caffeine use disorder."  "In reality," he writes, "DSM is a kind of symptom description classification... By adopting DSM, psychiatry discarded the ideal of a nosological entity."  All this results in "the annihilation of psychiatry as a medical science."   These words deserve to be carved at the entrance-way of APA meetings in letters of fire.

            What's behind this shift from "disorders" to "symptoms"?  Dr Hojaij suggests that it might make psychiatry more accessible to patients.  Yet there is a more sinister interpretation:  Shifting the clinical gaze from disorders to symptoms makes psychiatry more accessible to primary care practitioners, who might otherwise feel themselves a bit at sea when it comes to "disruptive mood dysregulation disorder," but are quite capable of recognizing outbursts of anger in their pediatric patients and reaching for the pen to prescribe an antipsychotic.  The shifting of psychiatry to PCPs will result in a massive increase in prescribing, and some companies have been focusing attention on treating symptoms, not diseases.

            Dr. Hojaij concludes by calling DSM-5 "a mixed salad" with a "high water rate and very low substance." But this amusing characterization doesn't get at a deeper problem: the major diagnoses of DSM-5 are mainly artifacts.  Major depression, schizophrenia, bipolar disorder, the many "anxieties" -- they don't exist in Nature.  And this perversion of science will persist until the entire DSM is thrown out the window and we recommence nosology from ground zero -- in the hands of someone other than the guildmasters of the APA.

 September 28, 2017