Rejuvenating Abolitionism of Psychiatric Labels — Even Some Establishment Psychiatrists Embarrassed by New DSM-5

Bruce Levine, PhD
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After the American Psychiatric Association (APA) approved the latest version of its diagnostic bible, the DSM-5, psychiatrist Allen Frances, the former chair of the DSM-4 taskforce and currently professor emeritus at Duke, announced, “This is the saddest moment in my 45-year career of practicing, studying and teaching psychiatry” (“A Tense Compromise on Defining Disorders”).

The DSM-5 (the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders) will be released by the APA in spring 2013. However, a forlorn Frances states, “My best advice to clinicians, to the press, and to the general public—be skeptical and don’t follow DSM-5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication.”

For mental health professionals, this advice from the former chair of the DSM-4 taskforce is shocking—almost as if Colin Powell were to advise U.S. defense and state department employees not to blindly follow all administration orders.

Particularly upsetting for Frances is the DSM-5’s pathologizing of normal human grief. On January 7, 2013 in “Last Plea To DSM-5: Save Grief From the Drug Companies,” Frances writes, “Making grief a mental disorder will be a bonanza for drug companies, but a disaster for grievers. The decision is also self-destructive for DSM-5 and further undermines the credibility of the APA. Psychiatry should not be mislabeling the normal.”

In the DSM-4, which Frances helped create, there had been a so-called “bereavement exclusion,” which stated that grieving the loss of a loved one, even when accompanied by symptoms of depression, should not be considered the psychiatric disorder of depression.

Prior to the DSM-5, the APA had acknowledged that to have symptoms of depression while grieving the loss of a loved one is normal and not a disease. Come this spring, normal human grief accompanied by depression symptoms will be a mental disorder.

Psychiatry’s official diagnostic battle is over. Mental illness gatekeepers such as Frances who are concerned about further undermining the credibility of the APA have lost, and mental illness expansionists —psychiatry’s “neocons”— have won.

Other New DSM-5 Mental Illnesses

The pathologizing of normal human grief is not the only DSM-5 embarrassment for Frances (see his December 2012 blog: “DSM 5 Is Guide Not Bible—Ignore Its Ten Worst Changes”).

Get ready to hear about a new mental illness diagnosis for kids: “disruptive mood dysregulation disorder” (DMDD). Frances concludes DMDD “will turn temper tantrums into a mental disorder.”

The APA, somewhat embarrassed by the huge increase of children diagnosed with “pediatric bipolar disorder” in the last two decades, wanted to give practitioners a less severe diagnostic option for moody kids. However, Frances’s fear is that DMDD “will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children. . . . DSM 5 should not be adding a new disorder likely to result in a new fad and even more inappropriate medication use in vulnerable children.”

The DSM-5 also brings us “minor neurocognitive disorder”—the everyday forgetting characteristic of old age. For Frances, this will result in huge numbers of misdiagnosed people, a huge false positive population of people who are not at special risk for dementia. And he adds, “Since there is no effective treatment for this ‘condition’ (or for dementia), the label provides absolutely no benefit (while creating great anxiety) even for those at true risk for later developing dementia. It is a dead loss for the many who will be mislabeled.”

“Binge eating disorder” has also now made it to the major leagues as an official DSM-5 mental illness (moving up from a non-official mental illness status in Appendix B in DSM-4). What constitutes binge eating disorder? Frances reports, “Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness called binge eating disorder.”

Frances’s “10 Worst Changes” in the DSM-5 also include the following: “First time substance abusers will be lumped in definitionally with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause.” DSM-5 also introduces us to the concept of “behavioral addictions,” which Frances points out “eventually can spread to make a mental disorder of everything we like to do a lot.” Additionally, Frances reports  that “DSM 5 will likely trigger a fad of adult attention deficit disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs.”  And Frances adds that “DSM 5 obscures the already fuzzy boundary between generalized anxiety disorder and the worries of everyday life.”

Brief History of the DSM

The first DSM was published in 1952 and lists 106 disorders (initially called “reactions”). DSM-2 was published in 1968, and the number of disorders increased to 182.

Both the first DSM and DSM-2 included homosexuality as a mental illness. In the 1970s, coinciding with the heightened significance of the DSM was the rise of gay activism. Thus, the elimination of homosexuality as a mental illness became the most visible psychiatric-political issue. Gay activists staged protests at American Psychiatric Association conventions. The APA was fiercely divided on this issue, but homosexuality as psychopathology was ultimately abolished and then excluded from the DSM-3, published in 1980.

Though homosexuality was dropped from DSM-3, diagnostic categories were expanded in the DSM-3 to 265, with several child disorders added that would soon become popular, including “oppositional defiant disorder” (ODD).

DSM-4, published in 1994, has 297 disorders and over 400 specific mental illness diagnoses. L.J. Davis, in the February 1997 issue of Harper’s, wrote a book review of the DSM-4 titled “The Encyclopedia of Insanity: A Psychiatric Handbook Lists a Madness for Everyone,” wrote that the DSM-4 “is some 886 pages long and weighs (in paperback) slightly less than three pounds; if worn over the heart in battle, it would probably stop a .50-caliber machine-gun bullet at 1,700 yards.”

Mental illness expansionism in the DSM-5 is no laughing matter for Frances who reminds us: “New diagnoses in psychiatry are more dangerous than new drugs because they influence whether or not millions of people are placed on drugs—often by primary care doctors after brief visits.” Though the APA claims that DSM-5 will not significantly add to the DSM-4 total of mental illnesses, by one DSM-5 declaration alone—eliminating the bereavement exclusion to depression—they will have created millions more mentally ill people.

DSM: Dogma or Science?

How exactly do certain human behaviors become a mental illness? It comes down to the opinion of a board of trustees of the American Psychiatric Association. Davis writes in Harper’s, “First, and primarily, the DSM-4 is a book of dogma, though as theology it is pretty pedestrian stuff.”

Is the DSM dogma or, as establishment psychiatry would claim, science?

Two important aspects of a scientific instrument are validity and reliability. DSM scientific validity would mean that behaviors labeled as disorders and illnesses are in fact disorders and illnesses. And DSM reliability would mean that clinicians trained in DSM criteria agree on a diagnosis.

One historical example, a century before the first DSM, of a clearly invalid mental illness is drapetomania. Louisiana physician Samuel A. Cartwright was certain he had discovered a new mental disease. After studying runaway slaves who had been caught and returned to their owners, Cartwright concluded in an 1851 report to the New Orleans Medical and Surgical Journal that these slaves suffered from drapetomania, a disease causing them to flee.

While virtually all psychiatrists today rightfully mock the idea that fleeing slavery could be considered a valid mental illness, it was not until the 1970s that cultural upheaval and political protests persuaded the APA of the invalidity of homosexuality as a mental illness.

And while homosexuality was dropped from the 1980 DSM-3, oppositional defiant disorder (ODD) was added, and ODD is now a popular child and adolescent diagnosis. The symptoms of ODD include “often actively defies or refuses to comply with adult requests or rules” and “often argues with adults.” Is it any more valid to label teenage rebellion and anti-authoritarianism as a mental illness than it is to label runaway slaves as mentally ill?

Even if you believe that oppositional defiant disorder and all the other DSM disorders are in fact valid mental illnesses, for them to be considered scientific, they have to be able to be reliably diagnosed.

In a landmark 1973 study reported in Science, David Rosenhan sought to discover if psychiatry could distinguish between “normals” and those so “psychotic” they needed to be hospitalized. Eight pseudopatients were sent to twelve hospitals, all pretending to have this complaint: hearing empty and hollow voices with no clear content. All pseudopatients were able to fool staff and get hospitalized. More troubling, immediately after admission, the pseudopatients stated the voices had disappeared and they behaved as they normally would but none were immediately released. The length of their hospitalizations ranged from 7 to 52 days, with an average of 19 days, each finally discharged diagnosed with “schizophrenia in remission.”

Psychiatry was embarrassed by Rosenhan and other critics and knew if the DSM wasn’t fixed, they would continue to be mocked as a science. The 1980 DSM-3 was dramatically altered to have concrete behavioral checklists and formal decision making rules, which psychiatry hoped would solve its diagnostic reliability problem. But did it?

Herb Kutchins and Stuart A. Kirk are coauthors of two books investigating this claim of “new and improved” reliability of the DSM-3 and DSM-4: The Selling of DSM: Rhetoric of Science in Psychiatry (1992), and Making Us Crazy, DSM: The Psychiatric Bible and the Creation of Mental Disorders (1997).

Kutchins and Kirk detail a major 1992 study done to examine the reliability of the supposedly new and improved DSM-3. This reliability study was conducted at six sites in the United States and one in Germany. Experienced mental health professionals were given extensive training in how to make accurate DSM diagnoses. Following this training, pairs of clinicians interviewed nearly 600 prospective patients. Because of the extensive training, Kutchins and Kirk note, “We would expect that diagnostic agreement would be considerably lower in normal clinical settings.” The results showed that the reliability of the DSM-3—even with this special training—was not superior to the earlier unreliable editions of DSM, and in some cases it was worse. Kutchins and Kirk summarize:

What this study demonstrated was that even when experienced clinicians with special training and supervision are asked to use DSM and make a diagnosis, they frequently disagree, even though the standards for defining agreement are very generous….[For example,] if one of the two therapists….made a diagnosis of Schizoid Personality Disorder and the other therapist selected Avoidant Personality Disorder, the therapists were judged to be in complete agreement of the diagnosis because they both found a personality disorder—even though they disagreed completely on which one!…Mental health clinicians independently interviewing the same person in the community are as likely to agree as disagree that the person has a mental disorder and are as likely to agree as disagree on which of the…DSM disorders is present.

Kutchins and Kirk report there is not a single major study showing high reliability in any version of the DSM, including the DSM-4.

Is there any good news about the DSM-5? The APA just announced that its price for the DSM-5 will be $199 a copy, and this is good news for Allen Frances who reacted: “People are not likely to rush out to buy a ridiculously expensive DSM-5 that has already been discredited as unsafe and scientifically unsound. . .The good news is that its lowered sales and lost credibility will limit the damage that can be done by DSM-5.”

Bruce E. Levine, a practicing clinical psychologist, writes and speaks about how society, culture, politics and psychology intersect. His latest book is Get Up, Stand Up: Uniting Populists, Energizing the Defeated, and Battling the Corporate Elite. Below is Levine’s presentation entitled, ‘Psychiatry: Reform or Abolitionism?’ delivered at the 2012 NARPA conference. His Web site is www.brucelevine.net

 

9 COMMENTS

  1. \\\…The DSM-5 (the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders) will be released by the APA in spring 2013. However, a forlorn Frances states, “My best advice to clinicians, to the press, and to the general public—be skeptical and don’t follow DSM-5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication.”

    For mental health professionals, this advice from the former chair of the DSM-4 taskforce is shocking—almost as if Colin Powell were to advise U.S. defense and state department employees not to blindly follow all administration orders…///

    Bruce,

    Thank you for writing another great piece. My only criticism: You view Allen Frances as being somehow akin to Colin Powell, were Powell to suddenly advise against blindly following all administration orders.

    Colin Powell (who is still viewed, by many, as a ‘peace-maker’ and/or as a ‘reluctant warrior’ – despite his being the author of “Shock and Awe” strategy… and despite his having been *instrumental* in getting us into a completely needless war on Iraq) would indeed become – to many anti-war advocates – an instant hero, were he to assume such a genuinely radical, *anti-authoritarian* stance. And, yes, that would be a step forward for him. (But, surely, he’ll never become so contrarian.)

    On the other hand, *many* psychiatrists, including Frances, have long professed a view of the DSM (even and especially, of Frances’s beloved DSM-4), that it’s merely a book of *suggested* ‘diagnoses’; in their view, it is *never* to be used, as a ‘bible’ – ever.

    Does that seemingly ‘less-than-perfectly-orthodox’ stance make them bonafide members of the ‘critical psychiatry’ movement? Of course, it doesn’t…

    To read my full response (which became too long, to post, as a comment), you can find it in my blog, by clicking on the following link:

    http://beyondlabeling.posterous.com/a-second-open-letter-to-bruce-levine-dsm-psyc

    Respectfully,

    ~Jonah

  2. Thanks, Bruce. I’m especially concerned about two other new disorders in DSM5 that are getting very little attention. Feeling suicidal is no longer a “symptom” but has acquired the status of a disorder called Suicidal Behavior Disorder. And ditto with self-harm, which has now been declared to be Non-Suicidal Self Injury (NSSI). The task of medicalising suicide and self-harm is now effectively complete, a giant step backwards for suicide prevention.

  3. Bruce, I notice in your piece that you seem to see the success of the gay rights movement in getting homosexuality declassified as a mental illness as a positive first step in the fight against psychiatry as the APA understands it. This would make the LGBT community and gay-rights activists the natural political partners of anyone branded with a DSM diagnostic, but I’m afraid the reality is quite the opposite.

    The success of the gay-rights movement has been to force the psychiatric profession to accept and promote as true two things:

    1) that homosexuality is an unchangeable biologically-determined, inherited characteristic.

    2) that this characteristic has no deleterious effects on those who have it or society at large.

    You will notice that 1) is in fact nothing other than the “chemical imbalance” theory, with the only difference that if the effects of the imbalance are not deemed to be deleterious (2)the imbalance is then referred to as a “variation” rather than an imbalance. The underlying (or I should say under-lying) premise is the same. Notice for example that the studies used to show that homosexuality is inherited are practically identical in design (and in the flaws which invalidate them) to those used to show that schizophrenia is inherited.

    Counterintuitive though it might sound, the removal of homosexuality from the DSM was in fact a triumph for the biological model of psychiatry, a triumph for the notion that complex human behaviour such as sexual orientation (or “mental illnesses”) is determined by inheritance rather than the environment and is therefore unchangeable.

    Every time gay-rights activists affirm that homosexuals are “born that way” they are also affirming by implication that people diagnosed with a “mental illness” were born that way. Every time gay-rights activists deride “ex-gays” they are also deriding by implication the possibility of recovery for those diagnosed as mentally ill.

    The victory of the gay-rights movement was not and early victory of those who oppose DSM diagnostics; it was an early defeat.It cemented the way for the model of psychiatry behind the DSM-5 and the enormous harm psychiatry has caused in the last 30 to 40 years. I’m afraid in this the truth is a very inconvenient double-edged sword which cuts both ways.

  4. Another wonderful critique of OUR self-deluded nature, Bruce. Oops, sorry I forgot, its only “them” who are self-deluded. Interesting citing of an original honesty in the admission of “nervous reactions?”

    “The first DSM was published in 1952 and lists 106 disorders (initially called “reactions”).”

    Reflex reactions, perhaps? Yet lets NOT speak of that giant elephant in room of human mental health, “I am NOT an animal!”

    Perhaps as the great God conflicted nation begins to grow-up, as we face the challenges of the 21st century, we might get beyond the denial, the nonsense and the untold damage done in the name of America’s predatory, dominance urge?

    Most are happy here on MIA to use the word “predator” and predatory nature, in a description of big pharma’s behavior and its corruption of mental health care. Yet due to the great confusion about the “body” amongst so many American Christians, we cannot discuss the “nature” of mental illness as normal instinctual, stress reactions, for fear of cognitive dissonance, and the surreal Christian assumption that the mind has an “immaculate conception?”

    Why are we happy to embrace “systems theories” of the environment “out there,” while remaining loath to explore the environment within, and the complex positive & negative feedback systems of the body-brain? Why do we shy away from awareness of our own internal nature, with its unique sensitivity and capacity for overwhelming sensation?

    After the 1st world war, it quiet common to hear people say “my nerves are shot,” a description with a visceral (sensation) affect? But we’re now certain that PTSD is a far more accurate description, aren’t we?

    Readers may consider Peter Levine’s sage advice, although I doubt it very much, the psychic pain of cognitive dissonance and the instinctual need to belong, will overrule the courage required to face the nature of our human reality as it is, beneath our self-soothing needs of “I think therefore I am,” comfortably numb?

    “My approach to healing trauma rests broadly on the premise that people are primarily instinctual in nature – that we are, at our very core, human animals. It is this relationship to our animal nature that both makes us susceptible to trauma and, at the same time, promotes a robust capacity to rebound in the aftermath of threat, safely returning to equilibrium. More generally,
    I believe that to truly understand our body/mind, therapists must first learn about the animal body/mind because of the manner in which our nervous systems have evolved in an ever changing and challenging environment. (p, 225)

    However, there is an almost violent schism lurking in our cultural zeitgeist. Lets face it; the fight against evolution by the proponents of “creationism” and “intelligent design” is not really about professed gaps in the fossil records; its about whether or not we are basically animals. (p, 225)

    In fact, the word instinct is rarely found in modern psychological literature. Rather it is purged and replaced with terms such as drives, motivations and needs. While instincts are still routinely drawn upon to explain animal behaviors, we have somehow lost sight of how many human behavior patterns (though modifiable) are primal, automatic, universal and predictable. (p, 231)

    In the Beginning, before the Word, was Consciousness.
    The primal consciousness in man is pre-mental,
    and has nothing to do with cognition.
    It is the same as in the animals.
    And this pre-mental consciousness remains
    as long as we live the powerful root
    and body of our consciousness.
    The mind is but the last flower, the cul-de-sac.
    _D. H. Lawrence. (p, 236)

    The capacity to anticipate and predict movement is the basis of what consciousness is all about. Any animal that is able to modify its behaviors (in response to changes in its situation) is imbued with some form of consciousness. In this way “mindedness” derives directly from improved organization and execution of bodily movement in time and space. The father of modern neuro-physiology, Sir Charles Sherrington put it this way; “The motor act is the cradle of the mind.” (p, 239)

    Only man routinely becomes lost in regret for the past and fearful of what will happen in the future, causing us to be disconnected and adrift from the now. One might even call this lack of living in the present moment a modern-day malady. It appears to be a by-product of a loss of connection with our instinctual animal nature. (p, 240)

    “We are exquisitely social creatures. Our survival depends on understanding the actions, intentions and emotions of others. Mirror neurons allow us to grasp the minds of others not through conceptual reasoning but through direct simulation. By feeling – not by thinking” _Giacomo Rizzolatti. (p, 241)”

    Excerpts from, “In an Unspoken Voice,” by Peter Levine, PhD.

    Best wishes to all,

    David Bates.

  5. The DSM-5 is so ludicrous that it has become the prime example of snake oil peddling and flim flam skullduggery. It’s amazing that anyone with half a brain even pays any attention to this pseudoscientific piece of junk. Tracing the develoment of the DSM from the beginning to now gives an interesting look at how psychiatry has descended into total quackery. How can anyone take any of this seriously??????!!!!!!

  6. Thank you so much for this article. I have been, what I believe, wrongly misdiagnosed. The psychiatrist I see lives by the DSM, so before accepting her diagnoses, Ive been researching what exactly the DSM is. Reading articles like yours really supports my intuitive thoughts that I have indeed, been mislead. Thank you again.

  7. I went and read Allen Frances’s article. I only want to comment on Binge Eating Disorder. Binge eating isn’t gluttony. It comes from malnutrition. It is an instinctive body response, not a psych disorder at all. I suffered from this for three decades so I know first-hand what it’s like. Two points: Since it’s not a mental disorder, it’s a nutritional disorder, as are most eating disorders, and I think psychiatry needs to butt out.

    Secondly, the DSM does acknowledge this problem but because it doesn’t define it properly, it does real binge eaters a disservice. It makes no quantity distinction. So some people might eat two sandwiches and then, be terribly upset. That’s considered a binge according to the DSM. Others might eat ungodly quantities of food and then, be at serious risk for stomach rupture especially if they don’t or can’t throw up. I was one of those large quantity people and I never threw up. I guess folks are completely unaware of what this does to a person. I was so disabled by it that I couldn’t go to school or work a job or have a social life anymore. After a binge I could barely stand up, sometimes passed out, and was so sick I’d be in bed (and not at work) for days on end. In bed, lay there and groaned in agony, burping and farting all day. My stomach was so stretched that yes, it was seriously dangerous. Each time a person binges the risk of rupture increases. Not only that, at times, I ate things that weren’t food. Most of this happened because I was suffering from malnutrition, not some impulse problem.

    I tended to be thin, and often, underweight, so I couldn’t get anyone to believe me. For thirty years I got laughed at and poked fun at by my psychiatrists. Many of them assumed I was lying completely about the severity of it. I wasn’t. I was told that it was “impossible.” It isn’t. I was told I was “faking it,” and for godsakes no. This is why I ended up in MH “care” in the first place, where I never belonged.

    After three decades, still, no one really understood nor cared nor listened. They couldn’t fix it, so instead, they tried to fix the other nonexistent mental disorders. I know I am not the only one because others have contacted me and told me they suffer likewise.