Boycott DSM5? Why Not?

Captain Boycott was the British land agent for Lord Erne of County Mayo who, in 1880, was ostracized from the local community as part of the Irish Land League’s campaign for agrarian tenants’ rights. Rather than harvest Lord Erne’s crops, his tenants let them rot in the fields, obliging the good captain to leave Ireland. Wittingly or not, he left behind his name, which was promptly applied to a protest tactic that has proved effective over the years.

I still don’t eat Iceberg lettuce or Thompson seedless grapes. And if grapes, why not the DSM?

The DSM5 proved to be the center of conversation and contention at the American Psychiatric Association’s annual convention conducted in Philadelphia May 5 to 9. Even as the convention was concluding, a host of articles were published in the print and on-line press trumpeting the news that the DSM5 Task Force had backed off including several proposed and controversial additions to the new DSM. Time magazine and Benedict Carey of The New York Times reported that two of the more controversial diagnoses, Attenuated Psychosis Syndrome and Mixed Anxiety Depressive Disorder, have been dropped because the field testing research undertaken by the Task Force did not provide sufficient supporting data. The “bereavement exception” to the diagnosis of Major Depression has also been re-inserted, if only as an explanatory footnote; and public commentary has been re-opened on the DSM5 website until June 15 although the projected publication date of May, 2013, remains unchanged.

Medpage Today printed a comprehensive summary of all the changes in the draft DSM5 to date, “DSM5: What’s In, What’s Out,” by John Gever; and Allen Frances, the editor of DSM IV and foremost critic of the new DSM, breathed a “Sigh of relief…” in his blog on Psychology Today. “… For the first time in its history, DSM5 has shown some … capacity to correct itself … the first step in a systematic program of reform … before DSM5 can become a safe and scientifically sound document.” He topped off his comments in an op-ed published in The Times May 11: “… Psychiatric diagnosis is simply too important to be left exclusively in the hands of psychiatrists. They will also be an essential part of the mix but should no longer be permitted to call all the shots.”

While I’m a great admirer of Dr. Frances, I don’t share his optimism regarding psychiatry’s ability to reform itself or the DSM5 or psychiatrists’ willingness to share clinical decision-making or continued development of the DSM with other professional stakeholders. Those who have power don’t surrender it so quickly, unless under considerable duress. And I don’t believe the “public outrage” and the “uniformly negative press coverage” which Dr. Allen cites as instrumental in the APA Task Force’s modest turnaround, even if augmented, will prove sufficiently persuasive. Hence my idea for a boycott.

An article published in The New England Journal of Medicine on May 17, “Mental Illness – Comprehensive Evaluation or Checklist?”, which expresses a point of view sharply if politely critical of the DSM5, persuaded me that a boycott might not seem so far-fetched. The authors make three fundamental observations: first, the DSM task force has failed to answer the key question about the disorders that it presumes to categorize: “What are they?” In fact, the authors contend that the APA and its DSM task forces, dating from the DSM III, have failed to answer that question. Which is a polite way of re-stating Kirk and Kutchins’s and Bentall’s contentions that the DSM’s presumed disease entities, i.e., the mental illnesses it categorizes, have no construct validity, no data to support their existence. Accordingly, the DSM and its last four editions, III through IV TR, ignore the issue of causality – what’s behind these illnesses – and have substituted symptoms and their categorization in its stead. These same symptoms, the authors remind us, are common to a multitude of disorders and distinguishing between them as illness-specific is further confounded by continued poor inter-rater reliability. To bypass this problem, the DSMs have reduced presumed illnesses to symptom checklists which are expedient, cost effective and serve more the interests of insurance companies and government monitors than those of clinicians and their patients. In practice, the checklists have replaced what the authors call the “bottom-up method of [assessment and] diagnosis … based on a detailed life history , painstaking examination of mental status and corroboration from third-party informants …”

The authors end with a biting admonition to psychiatrists: “ … [Only when psychiatrists address] psychiatric disorders in the same way that internists address physical disorders, explaining the clinical manifestations … by the causal processes and generative mechanisms known to provoke them … will psychiatry come of age as a medical discipline and a field guide cease to be its master work” (italics mine).

Medical snobbery and one-upmanship aside, that statement tells me that psychiatry and its status within the medical profession hasn’t moved off the dime, that it’s still back where it was pre-DSM III. As per Kirk and Kutchins, one of the key motivating factors for the APA in assembling the DSM III was to demonstrate to psychiatrists’ medical brethren that psychiatry had a solid scientific base and qualified as a medical discipline as valid as any other. The DSM III and its subsequent iterations appeared to have secured professional legitimacy for psychiatry. Now it would seem that the brouhaha stirred by the DSM5 has succeeded in blowing the smoke from the mirror, revealing anew the DSM’s original flaws – lack of construct validity and poor inter-rater reliability. Probably the best reason to not buy, to boycott the new DSM.

And what would be the consequences? For starters, the APA would lose a lot of money. As Allen Frances has pointed out, the DSM, which has sold in the millions over the past thirty years, has been a “cash cow” for the APA. More importantly, the thirty-year long momentum to label more and more individuals as mentally ill and to pathologize their behavior would be checked, even if not stopped entirely. Which would help to undermine the DSM as a tool of social control.

And what would clinicians use in its stead? Well, the DSM IV TR is still in circulation and could be used as a diagnostic checklist, its current principal function. Clinicians could also begin relying solely on the ICD, the International Classification of Diseases manual, which is itself a diagnostic checklist and must be used by providers, in accordance with U.S. law and international treaty, when submitting bills to CMS, the Center for Medicare & Medicaid Services, and to insurance companies. Coincidentally, the ICD-9 U.S.CM (clinical modification), which has been in use in this country for the past twenty years, was scheduled to be replaced by the ICD-10 in the Fall of next year. If you didn’t know already, the new ICD will contain 46,000 disease classifications, more than triple ICD-9’s current 14,000. Talk about bureaucracy. I guess the Feds and the insurance companies have been busy parsing every illness known to medical science. In that spirit, the DSM5, now scheduled for release in May of next year, is being designed to contain a DSM → ICD 10 crosswalk as an aid to clinicians.

In any event, Kathleen Sibelius, Secretary of Health and Human Services, the Federal agency that oversees the use of the ICD, recently announced postponement of the issuance of ICD 10 until 2014. Seems the necessary software programs are still being written. Something to look forward to!

It would be great to boycott use of the ICD as well; which would rattle the cage of the entire public mental health system; which serves to demonstrate how intertwined and intellectually bankrupt and financially fragile the whole mental health system is. A mirror image, so to speak, of our banking and financial systems. No, I would settle for a boycott of the DSM5 to get things rolling. As I said earlier, I have no trust that continued pressure, even the threat of a boycott, would deter the APA from publishing #5.

At this point, the question I’d like answered is whether anyone reading this agrees that the idea of a DSM5 boycott has some merit. Or is it just a crazy idea that would never fly? And if any one or more of you have any ideas about how to test the waters, how to get the word out to see if other folks, particularly the clinicians, who would be most likely to purchase copies, think a boycott could be mobilized.

Let me know what you think. Remember, don’t mourn, organize! Lots of work still to be done!

References:

American Medical Association, “ICD-10 Code Set to Replace ICD-9,” http://www.ama-assn.org/ama/pub/physician

Bentall, R., Madness Explained: Psychosis and Human Nature, Penguin Books, London, 2004

Carey, Benedict, “Psychiatry Manual Drafters Back Down on Diagnoses,” The New York Times, May 9, 2012, www.nytimes.com

Frances, Allen, “Diagnosing the D.S.M.,” The New York Times, May 11, 2012, www.nytimes.com

, “Wonderful News: DSM 5 Finally Begins Its Belated and Necessary Retreat,” May 2, 2012, www.psychologytoday.com/blog

, “Is DSM5 a Public Trust or an APA Cash Cow,” January 3, 2012, http://1boringoldman.com

Gever, John, “DSM5: What’s In, What’s Out,” May 10, 2012, http://www.medpagetoday.com/MeetingCoverage/APA

Kirk, S.A., Kutchins, H., The Selling of DSM: The Rhetoric of Science in Psychiatry, Aldine de Gruyter, New York, 1992

McHugh, Paul and Slavney, Philip, “Mental Illness – Comprehensive Evaluation or Checklist,” The New England Journal of Medicine, May 17, 2012, http://www.nejm.org

Phillips, James, “DSM5 In the Homestretch – 1. Integrating the Coding Systems,” March 7, 2012, http://www.psychiatrictimes.com/blog/phillips

Szalavitz, Maia, “DSM5 Debate: Committee Backs Off Some Changes, Re-Opens Comments,” Time Magazine, May 3, 2012, www.time.com