Viewpoint: Stop Critiquing the DSM 5

The manual still has merit—but the APA needs to do a better job explaining how DSM 5 captures key facts about human suffering.

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The newly revised Diagnostic and Statistical Manual of the American Psychiatric Association—DSM 5—has just been released at the Association’s annual meeting in San Francisco.  Not since the critics uniformly declared Adam Sandler’s Jack and Jill ‘the worst movie ever made’ long before it actually was shown in a theater has something not yet put out in public gotten such full-throated critical panning. Consider some of the current headlines: “DSM 5: A Manual Run Amok” and my personal favorite, “Psychiatry’s New Diagnostic Manual: “Don’t Buy It. Don’t Use It. Don’t Teach It.

It does not end there. There are also a flood of new books critical of the DSM 5, such as Gary Greenberg’s The Book of Woe: The Making of the DSM-5 and the Unmaking of Psychiatry; Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis by Allen Frances; and Allan V. Horwitz and Jerome C. Wakefield’s All We Have to Fear: Psychiatry’s Transformation of Natural Anxieties into Mental Disorders, just to name a few.

(MOREMental Health Researchers Reject Psychiatry’s New Diagnostic Bible)

The critics are going way too far. The DSM is often described as “the bible of the mental health field”—an unfortunate misnomer that leaves it open to attack. It should really be called “The best we know so far about mental disorders” or perhaps “Our best effort to properly classify complicated human behavior.”

But a bigger problem is that the editors don’t know how to defend against the attacks. They keep saying that they are attentive to critics, that the process has been transparent and that they have posted draft versions online. But noting that anyone and everyone could comment on the drafts of DSM 5—and that more than 10,000 comments were received—makes the book sound more like a popularity contest than a scientific endeavor. Perhaps out of fear that the DSM 5 will not be seen as objective, the editors have stumbled in their defense of their work. But that doesn’t mean that a rationale doesn’t exist for what they have done.

The most common criticism is that the book proliferates diseases—kids who throw frequent temper tantrums are now afflicted with ‘Temper Dysregulation Disorder with Dysphoria,’ and those who are bereaved are lumped in with the depressed. Others critics note that Americans are over-medicated already and all DSM 5 does is provide more reasons to prescribe more pills. And some, such as the NIMH director Thomas Insell, argue that trying to lump and cluster symptoms without grounding them to hard causal evidence drawn from genetics and neurology is bound to create categories with no reliability or foundation.

(MORE: Viewpoint: My Case Shows What’s Right—and Wrong—about Psychiatric Diagnoses)

Lets get rid of that last complaint first. The view that the only medical classifications that are valuable are those grounded in molecular biology can be dismissed out of hand. Meteorologists predicting the weather, climate scientists studying global warming, forestry experts, and those dealing with earthquakes do not have coherent explanations in atomic physics for their categories or for their causes. But their categories are accepted because they work—giving us predictable and actionable knowledge about the world. The same ought be the test of DSM 5.

As for proliferating diseases, the DSM 5 is, as critics note, making value judgments. What the editors need to do is embrace that fact, not run away from it in the hope of giving the book the appearance of eternal verity. It is a revision—there is no eternal verity to be had. Classifications, including those in mental health, change over time as our cultures and societies change. Get used to it.

The manual presumes that being an autonomous, self-governing, independently functioning person is a good thing and creating children who can mature this way is also a good thing. But that doesn’t turn the manual into a plot by drug companies and their henchmen to impose a way of life on the rest of us. The capacity to lead one’s life and flourish happens to be a guiding principle in America today and in most parts of the world. Not every culture holds this view, nor has this been a primary value throughout history. But, if grief makes it hard for you to function, then you have a disorder.  If having frequent temper tempers leads other kids and teachers to shun you, then your chance of becoming an independent person capable of social engagement may be diminished. Is it easy to take potshots when what used to be normal or ignored is now categorized as illness. But treating what is ‘normal’ as disease is wrong only if you think acne, rashes, fevers, warts, coldsores, colds, osteoarthritis and dental cavities are just fine too.

Which leads directly to the other main gripe about DSM 5—the overuse of medications. There need not be a connection between a behavior or trait appearing in the DSM 5 and having your doctor write a prescription. If we really want doctors to stop prescribing so much medicine to us and our kids then we should stop asking them to do so, bring direct-to-consumer advertising to an abrupt halt, slap a steep co-pay on elective drug use and start paying doctors to talk to us instead of drugging us.

The DSM 5 is not without flaws—it’s not yet linked to emerging research on genetics and neurology, for one. But the APA and the manual’s authors need to do a better job of explaining why it still has merit in that it captures key facts about human suffering, shows enough utility to be used by many professionals and patient from diverse background, and provides help to those who cannot function in a complex and rapidly evolving world. The mentally ill and the rest of us deserve it.

11 comments
Picaro
Picaro

You right Dr.<I assume) Caplan you absolutely right. The next generation of the DSM 5 should be TR for "Title Revised". They ought to at least take out the word Statistic from the title given than from it development going back to DSM I, II III IV (I have them all, I go back that far) and all its revision STATISTICS haven't really been a major component. The word implies that the DSM has strong scientific foundation when in reality it does not. In fact from what I have been reading science has been basically ignored, over-extrapolated, and even in some cases some of the claims made in the DSM, the scientific research literature had already discovered that the reverse is true. 

Am not sure I agree with the exact titles as you suggested, but your going in the right direction. The title should be a lot more ethical and based more on reality than the delusions we sometimes have about its origin, ability and accuracy. 

But I disagree with you that we ought to Stop Critiquing. I know that some of the criticisms is base on more of the same, Some of the suggestions seem to be worst that the condition that we want to fix or there is a lacking understanding of science, and the real process under which the DSM system have been developed. Some other criticisms are rather immature, based to much on anecdotes and personal experience. Some critiquing make extraordinary claims with out ever been tested (Like the late Carl Sagan used to say "Extraordinary claims requires extraordinary evidence").

 

It is exactly critiquing and refuting is one of the principles of the scientific method.  If you haven't notice most if not all major breakthroughs in all sciences have come from someone questioning the status qua, tradition, and even those things we were absolutely sure that we where right (as you may know one of the founders of the British Royal Society back in the time of Newton made a big stink about the physical impossibility of Heavier than Air Flight). We in the mental health field make way too many claims for which we have no evidence or never have tested. A bad habit we ought to break for our patients well being. There something unethical about so much hot air.


Your name sake Paula Caplan is one of my heroin regarding the refuting of the DSM system. She has a lot of accurate statement about the DSM that we ought to look at. Some of the diagnosis are just as invalid and unreliable as the that phrenology  assessment technique we used to laugh so much about in course of ethics. And some of the treatment we provide are as effective and safe as bloodletting. You ought to consider that they reason there is so much critiquing is because there is a lot to criticize. Compatibly there isn't much criticizing for diagnosis such as fever, HIV, Hepatitis, even a broken bone. The reason is that in the Medical Science they have a lot more unbiased measuring devices such as a thermometer,   blood test and even an X-Ray. We lack that in the Psychiatric Science, and if we ever hope to gain some better measuring devices (hopefully MRI, CTScan, EEG will be developed). The only thing we seem to have is empirical research. Unfortunately most clinicians lack the training in the science they need to have before they will be able to provide Evidence Based Treatment and Assessment. We are poorly prepare to implement such vast  protocol.


I am sorry I wrote too much to make two points. Yes we ought to change the title and no we shouldn't stop criticizing or

critiquing (at least do it with some intelligence and non mean spirited)

kalensar
kalensar

Arthur, your authoritarian outlook for classifying temper tantrums of kids as a disorder is antithetical to being a self-governing adult.

 More than two weeks for grieving over the loss of a loved one is considered a disorder? Really!?

This reads more like a manual for being top slave-driver. 

bojimbo26
bojimbo26

" If I write a bit of bumf in this book , I will get my name published " .

richard55
richard55

Useful comments, except from the idea that criticism should be silenced, but would love to hear your comments about "cultural and religious practices". DSM5 (in the DID chapter) states that these can be contra-indicators to the diagnosis of a disruption as a disorder. How do psychiatrists possess the expertise in these areas if they don't work with other academic disciplines? The bibliography Spiegel produced was derisory in non-psychiatric terms.

Similarly, it would be good to see some championing of the de-colonializing implications. The APA should be proud of these and should make some more noise about positive developments such as this which are currently slipping under the radar. http://www.academia.edu/3566123/Is_disciplinary_isolation_a_mental_disorder

postingonline42
postingonline42

"If we really want doctors to stop prescribing so much medicine to us and our kids then we should stop asking them to do so," Right, like the people who had their baby taken away from them because they wanted a second opinion before major surgery at a hospital that already botched things http://abcnews.go.com/GMA/video/california-police-baby-parents-improper-hospital-discharge-19081468

My son needs therapy. yet we are terrified that when we seek it, we will get one of those 15-min-per-session doctors that adjust (increase) medication until things "get better" and that if we refuse it, we will be treated like christian scientists refusing to give a cancer kid timely chemo. It's darned if you don't, darned if you do. 

Norm
Norm

Mr. Caplan, FYI, meteorlogists predicting the weather, climate scientist studying global warming, etc. ALL have coherent explanations traceable back to atomics physics for their categories and their causes.  Only the medical specialty known as psychiatry has little or no traceability back to physical evidence, a trait it shares with all other pseudocsciences, quack cures, and get-rich-quick schemes.  The DSM V makes up diseases so that drugs may be sold.  Psychiatrisats have no interest in raising autonomous, self-governing, independently functioning persons, only drug-dependent, anxious ones.  Let's stop calling normal human behavior and feelings a disease, and stop pushing drug on children.


 

Leftcoastrocky
Leftcoastrocky

"elective drug use" -- how does that differ from non-elective drug use?

FuzzyPotato
FuzzyPotato

Stop critiquing?  I'm sorry, that's the most pathetic thing ever said.  Without commenting on the value of said document, things that are published or release - anything - will be critiqued.  That's just the nature of the beast.  Welcome to humanity.

Tom55
Tom55

agreed, case of the emperor having no clothes

splash
splash

psychiatry/psychology is a pseudo science that is akin to alchemy of the bygone era.

Picaro
Picaro

@Leftcoastrocky I have met some drug users that I would consider "Ego Syntonic" and actually given the country they live in and the economic resources they have they do not meet non of the eleven impairment or criteria claimed in the DSM IV and V. I do not know if I could do that if I would ever become dependent on substances but this guys seem to have adapted well to what I would call predicament. For them scoring drugs and buying them look just like a minor inconvenient.