Why all the fuss over DSM-5? Why did Robert Spitzer, the editor of DSM-III, begin to protest about the “secrecy” surrounding its production as early as 2007? Why did Allen Frances, editor of DSM-IV, begin in 2009 to challenge the American Psychiatric Association’s (APA) announced goal that when making DSM-5 “everything is on the table”? Why did he dispute the APA’s position that there had been enough progress in neuroscience to call for a “paradigm shift”? And why did Frances and others go on to protest repeatedly what they viewed as DSM-5’s “medicalization of normality?”
So, why all the fuss about DSM-5? After all, most psychiatrists, psychologists, social workers, and counselors don’t usually pull out their copy of the current DSM to run their fingers down the diagnostic criteria when they are required to make a diagnosis. And family doctors and internists, who prescribe over 80 percent of all psychotropic medications, almost never do.
There is a fuss for two main reasons. First, whether a health insurance company will pay mental health professionals for their recommended treatment for patients and clients hinges on the diagnosis the clinicians provide.
Second, and more vital, is that the diagnoses in the DSMs have come to affect the daily lives of millions of people in the United States, not to mention those abroad, since the DSM is translated into many languages. For these people much hangs upon whether a particular diagnosis is in the manual or is not. At stake is their treatment, insurance coverage, and decisions affecting such fundamental matters as where they will live, what jobs they can hold, and how their children will be educated. Significantly, the DSM is used by public housing authorities to decide eligibility, by employers who must comply with the Americans with Disabilities Act, and by public school systems to determine whether to provide free special services for students. In the criminal justice system, the DSM is employed by lawyers, judges, and prison officials. To these circumstances must be added the unfortunate reality that the stigma that may accompany one particular diagnosis but not another is of considerable concern to individuals who may be identified as having a mental disorder.
A short thirty years ago, this panoply of affairs (aside from problems with stigma) did not exist. The first two of the APA’s diagnostic manuals of 1952 and 1968 were mere blips, small spiral-bound booklets of some 130 pages, more overlooked than consulted by clinicians, and totally unknown to the general public. The third edition, the DSM-III of 1980, a massive hardbound volume of 494 pp., changed within a decade the benign neglect that the manual had been receiving. A revolution in American psychiatry had occurred. DSM-IV (1994) was a reiteration of III, and greatly expanded. By 2000 the revised IV was nearly 1,000 pages. In spite of some reorganization of chapters and several new diagnoses, DSM-5 bears a remarkable resemblance to its famous ancestors.
DSM-III discarded the psychoanalytic emphasis of DSM-II, with its theories of unconscious conflict as the root cause of most psychopathology. And then in a quest for diagnostic reliability—at that time mired in a state of abysmal inaccuracy—DSM-III inaugurated a new approach to mental disorders based solely on observable signs and symptoms. Checking off these “operational (eventually diagnostic) criteria” became the goal of an increasing number of psychiatrists. (Interestingly, the notion of operational criteria was derived from the principle of “operational analysis” as the road to knowledge, first propounded in 1927 by the Harvard physicist P. W. Bridgman.) In DSM-III mental disorders were now neatly divided into discrete descriptive categories, and the psychoanalytic idea of disorders ranging along a spectrum from normal to severe psychopathology was dropped. With a few exceptions—the most notable being Autism Spectrum Disorder—DSM-5 remains categorically based like III.
Yet there are notable differences between III and 5, and they speak to historical developments in psychiatry. Much attention has recently have been given to the new diagnoses to be found in 5, but some matters have received less publicity. One is that the multiaxial system, proudly introduced by Spitzer, has been shelved by the makers of 5.
For these individuals four points were at issue. To start with, it had been Spitzer’s idea that there be a separate axis (Axis II) to call attention to underlying personality disorders that might escape notice when clinicians focused on acute syndromes that had brought the patient into treatment. But that diagnostic neglect has mostly changed since 1980, a time when many researchers had challenged the authenticity and validity of what they considered to be the “soft” personality diagnoses. Today personality disorders are regarded as “legitimate,” drawing a great deal of clinical (and even research) attention, and therefore are not being placed on a separate axis. Second, Spitzer had been concerned that clinicians might not want to use Axis IV (“Severity of Psychosocial Stressors”) and V (“Highest Level of Adaptive Functioning Past Year”), and his surmises turned out to be largely correct. Over the years, a significant group of clinicians have complained that using the multiaxial system was burdensome and time consuming, and the makers of 5 decided to respond to this. The observer is tempted to ponder if this development in 2013 also speaks to psychiatrists’ greater attention to short “med-checks” as opposed to their psychotherapeutic focus 30 years ago.
The third point regarding the multiaxial system is that the architects of the new volume decided that they did not want to draw a sharp line between mental and medical conditions, as DSM-III’s Axis III (“Physical Disorders or Conditions”) had often dictated. Spitzer himself wanted DSM-III to be a tool to portray psychiatry as scientific in order to combat the anti-psychiatry movement of the 1960s and early ‘70s. However, the present builders of 5, with their goal of tying psychiatry to biology as openly as possible, have sought to reiterate that psychiatry, as a medical discipline, shares vital links with science. Finally, Spitzer’s multiaxial innovation was the victim of unintended consequences. It often occurred that health insurance companies reimbursed less for Axis II disorders, taking the listing of Axis I (“Clinical Syndromes”) before Axis II to mean Axis II disorders somehow ranked “below” Axis I disorders. (It did not help, of course, that personality disorders could be more expensive to treat than some acute Axis I disorders, since personality disorders often called for lengthy psychotherapeutic intervention.)
Another historical change from DSM-III to DSM-5 is that much greater attention was paid to possible monetary conflicts of interest of the DSM-5 Task Force and Work Group members than had ever been the case for the developers of DSM-III. For one thing, the creation of III was the first time that the making of a new manual had involved large numbers of contributors. DSM-I and II had been written by small committees whose financial ties had never been a consideration. Thus, the ties of the makers of III were barely scrutinized. Furthermore, substantial payments to researchers and clinical consultants from pharmaceutical companies—the source of most conflicts of interest—were just beginning in the early 1970s when III was being constructed. Psychiatrists then were more likely to get grant money from their institutions and the NIMH than from private companies. But it was the very form of III, with its new and specific categories, that had beckoned the pharmaceutical industry to develop medications for recently developed diagnoses. The professional landscape altered. To urge the prescribing of the new drugs, companies now paid psychiatrists who had done research (often with industry grants), or had other experience with their products, to disseminate information about them, often at delightful small dinners.
By the time the creators of DSM-5 were assembled c. 2007, it was widely recognized that financial support from “Big Pharma” posed serious potential conflicts of interest. Already certain prominent psychiatrists had been exposed as taking large sums from the pharmaceutical industry that they had not disclosed to their home institutions. There were accusations that the reports and papers of some researchers had been written for them by commercial organizations. Eventually, during the process of making of DSM-5, the American Psychiatric Association (APA) did considerable vetting of ties with drug companies and the Task Force and Work Groups members had to publish financial disclosures. They had to agree that their aggregate annual income derived from industry sources (excluding unrestricted research grants) would not exceed $10,000 in any calendar year.
A final historical development was barely a fleck on the screen until several weeks ago. DSM-III had had the enthusiastic support of the NIMH. The bulk of the field trials of DSM-III were supported by a grant from the NIMH. Since its formal establishment in 1949, the NIMH and the APA have had a close relationship. As the APA began to contemplate a revision of DSM-IV in 1999, a partnership was formed between it and the NIMH, “with the goal of providing direction and potential incentives for research that could improve the scientific basis of future classifications” (A Research Agenda for DSM-V, 2002.)
Thus, it came as a great shock to almost all when Thomas R. Insel, Director of the NIMH, announced on April 29 of this year, just three weeks before the release of DSM-5, that the NIMH would no longer be guided by the DSM. Insel acknowledged that ever since DSM-III appeared in 1980, the manual had helped produce reliability in psychiatric diagnosis because it enabled more consistent communication among clinicians. However, its great “weakness,” he went on, was its lack of validity. By this he meant that a descriptive diagnostic category, as found in III or IV, might in reality encompass several different disorders having different etiologies and needing diverse treatments, thus making the current diagnostic category invalid. This was hardly news, it being widely recognized that Spitzer had sacrificed validity for reliability.
But Insel proceeded. The DSM was, “at best, a dictionary, creating a set of labels and defining each.” It was a collection of symptomatically-based diagnostic categories without any regard for etiology, at odds with the rest of medicine. “Patients with mental disorders deserve better, “ he declared, and proceeded to drop a bombshell: The NIMH would henceforth “be re-orienting its research away from DSM categories.” In their place the NIMH would create a new classification that would be based on “genetic, imaging, physiologic, and cognitive data” and would no longer support research projects based on the DSM nosology.
Have we come to the end of the DSM-III model, just 33 years after it was created? Is this the start of a new era that will bring to psychiatry the much-desired validity sought by Eli Robins and Samuel Guze in their famous 1970 paper, “Establishment of Diagnostic Validity in Psychiatric Illness”? Probably not right away. The NIMH has launched a new project, the Research Domain Criteria (RDoC), to transform diagnosis and create “precision medicine” such as has radically changed cancer diagnosis and treatment. But for the present, clinicians and the wider society that use the DSM, will have to rely on it or the International Classification of Diseases (ICD). After all, what else is there? The NIMH project is still in its infancy.
Insel predicts his project will be “a decade-long.” Even that seems overly optimistic considering the obstacles to such an etiological revolution. There is also the troubling feature that in his far-reaching blog he declaims that “mental disorders are biological disorders” with no mention of the role of human psychology.
History provides some perspective here. In 1845, a leading German psychiatrist, Wilhelm Griesinger, pronounced that “mental diseases are diseases of the brain,” which became the mantra of most medical students. Almost 30 years later, Theodor Meynert, Sigmund Freud’s teacher at the Vienna medical school, wrote in his textbook: “The reader will find no other definition of ‘Psychiatry’ in this book but the one given on the title page: Clinical Treatise on the Diseases of the Fore-Brain.” It was in reaction to such declarations, and their failure to advance knowledge, that the famous psychiatrist, Emil Kraepelin, coined the phrase “brain mythology.” Kraepelin, the father of the historic division of the psychoses into dementia praecox and manic-depressive illness, eschewed chasing after slippery etiologies and turned to describing what he observed. Freud, born the same year as Kraepelin (1856), was affected, as Kraepelin, by the identical disappointment with the sluggish progress in dealing with mental disorders. He went in another direction and created psychoanalysis. The two, Kraepelinian descriptive psychiatry and Freudian psychodynamic theories, have both contributed to our knowledge and have as well their recognized limitations. Importantly, they also stand as reminders of the arduous tasks involved in understanding human beings.
Hannah S. Decker is Professor of History at the University of Houston, Adjunct Professor of Medical History in the Menninger Department of Psychiatry, Baylor College of Medicine, and Adjunct Faculty member, Center for Psychoanalytic Studies, Houston. She has recently published The Making of DSM-III: A Diagnostic Manual’s Conquest of American Psychiatry (Oxford University Press, 2013.)