Why the DSM Is Mostly False | Nassir Ghaemi, MD

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From Psychiatry Letter: “A decade ago, the fifth revision of DSM (the  Diagnostic and Statistical Manual) was published by the American Psychiatric Association. This diagnostic system has been called the ‘Bible’ of psychiatry. The metaphor suggests some cultural realities. It tends to be worshipped; some view it as the literal truth; it can inspire, but it can be used to suppress dissent. The problem is that DSM can’t be a Bible and science at the same time.

In this article, I examine what the DSM system is and what it isn’t. The brief summary is that it has become more like a religion, and less and less scientific.

History

The origins of DSM go back to the first edition in 1952, and the second edition in 1968, but those earlier versions had little impact on the US profession, much less the world. This lack of impact mainly had to do with the fact that American psychiatry mostly was psychoanalytic in orientation. In psychoanalysis, little importance was given to diagnosis, unlike the medical tradition. Diagnoses were ‘labels,’ mere shorthand categories for communication. They weren’t ‘real’ and they didn’t represent ‘diseases.’ All psychopathology was about unconscious emotional conflicts, mainly dating to childhood; if the conflicts were normal or mild, they produced ‘neuroses’; if they were severe, they produced ‘psychoses.’ That was the extent of psychoanalytic nosology.

The American Psychiatric Association (APA) organized the first two editions of DSM mainly for administrative purposes. Those who ran mental hospitals needed to label the reasons patients were treated. Since psychoanalytic theory mostly ignored diagnostic labels, DSM terms often were taken from the alternative medical approach to psychiatry, popular in parts of Europe, and associated especially with the research of Emil Kraepelin (circa 1900), and other German and French psychiatrists dating back to Philippe Pinel (circa 1800) . . .

The Bottom Line

  • DSM is a social construction, based on ‘pragmatism’ much more so than science.
  • Use DSM administratively, not for best clinical practice.”

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9 COMMENTS

  1. “Research shows that this observation is common in bipolar disorder (10-50% of cases) but very rare in major depressive disorder (MDD, <1% of cases). In other words, antidepressant-induced mania happens almost exclusively in people who have bipolar illness."

    Wishful thinking … or the research shows that too many "mental health professionals" were not intelligent enough to read their DSM IV bipolar disclaimer?

    "Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder."

    As one who had all the common symptoms of antidepressant withdrawal misdiagnosed as "bipolar" – who had no history of "mental illness," prior to being put on an antidepressant – under the false guise of a "safe smoking cessation med."

    I'm guessing my theory is more credible than that of the author, albeit I do agree with much of what he/she said.

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    • In 104 patients, 100 with MDD, and 4 with BP, you would find 1 MDD with SSRI induced mania/hypomania, and 1 “unmasked”, uuggh, with BP.

      1% vs 25% chance. And I guess that’s around what’s seen in practice. 25 to 1. At that ratio it’s a 50/50 of either BP or SSRI “side effect”.

      That is disregarding the 95% probability to make a diagnosis.

      Reformulated: the diagnostician would have to take a 50% probability to a 95% one, or a less than 5% (to rule out). And, per the narrative, that can’t be done with the DSM, so!?, how!?. Judgement and psy magazines?. Fancy mind dices?.

      So, as a rule of thumb, what the text maker claims is patently false. It is useless in practice, it’s a false rule of thumb that also ignores the mandate that the diagnosis should be beyond doubt, or overwhelmingly probable. That given the heavy majority of MDD vs BP, won’t happen in practice.

      Cardiologists and surgeons know NOT to use rules of thumb that won’t take a diagnosis probability above 90-95% or below 5%, simple, they do that all the time…

      In 10,000 patients with MDD and 4 with BP, 1 BP per every 2,500 with MDD, you would find 100 with mania/hypomania caused by SSRI and 1 with “unmasked” BP, 100 to 1. That actually would make the prevalence of BP even rarer than before the 1980s remaking, fabrication of the current BP diagnosis, i.e. before the DSM-III. Won’t happen, didn’t happen even before the DSM.

      If I am not misremembering, the ratio before the 80s was around 10 to 1, per every ten MDD there was around 1 who in the future could be labeled BP, after he or she cycled, to be confident. And in those days, MDD ocurred in around 1 in a 1,000 people, not 30 in every 100 citizens, as it is claimed now. And BP was certainly not around the 5% it is claimed now.

      So, if MDD, as in ye old days, was 1 in 1,000, and now only 1 in 300 actually has MDD, the other 299 are overdiagnosed, or falsely diagnosed, a more accurate term, that means, there are 3 artificially created persons with BP induced by SSRIs, per every 1,000 citizens. Simple arithmetic…

      It would take 10,000 people to have 10 with MDD, as in ye old days, 3,000 treated with SSRIs, 30 with BP induced by SSRI, and only 1, only 1 with real BP, as in ye old days. A 30 to 1 ratio of false, medication induced BP, per every one with real cycling BP. Simple arithmetic. That makes current judgement and magazine reading, or using DSM, MONSTRUOUS, not the best anyone has… as the DSM claims itself to be: the best there is.

      Another category said claim falls into, is PREJUDICE. The text maker seems to be prejudiced to make diagnosis of BP. He/she claimed that lithium is the only, only, effective? treatment in psychiatry. So veering as many “patients” into the only effective treatment seems probable. To a hammer…

      So I guess it’s bias extends beyond diagnosis, but still falls into BP. Something Freudian prehaps?, transference/countertransferece?, projective identification?. Falsely diagnosed and projectively identifying as many?, who knows, it’s psychobabbly anyway…

      Lithium requires close monitoring, so more office visits, more billing, more income…

      There is another category that claim seems to fall into: deny any harm by SSRIs and by the pros prescribing them… with the claim of a panderer of BP diagnosis… and lithium effectiveness… a disvirtuous cycle…just like BP diagnosis in children…

      Which actually argues against another, main, dominant, claim of the linked text: using judgement and psy magazine readings as basis for “diagnosis”, uuuuh!. Simple logic and statistics prove at least one claim derived from said excercise, judgement and magazine reading, patently false. As far as I can see, easy…

      I am surprised the text maker is either unaware or oblivious, and bold enough to publish it, not once, but twice!. Seems recalcitrant…

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  2. Although, I must admit, in as much as I agree the “DSM is a social construction, based on ‘pragmatism’ much more so than science.” I personally believe it should be flushed, rather than being used “administratively.”

    Since it is really nothing more than a book of stigmatizations, that describes the iatrogenic illnesses, that can be created with the psych drugs.

    https://www.amazon.com/Anatomy-Epidemic-Bullets-Psychiatric-Astonishing-ebook/dp/B0036S4EGE

    And, for example, like the psychiatric industry’s systemic anticholinergic toxidrome poisonings of those misdiagnosed as “bipolar” …

    https://en.wikipedia.org/wiki/Toxidrome

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  3. This is a literary piece, is not a claim, or a set of claims, and it is not intended to be offensive.

    There can’t be scientific research in psychiatry since there is no theory from which to make scientific hypothesis to do research on them, period…

    Hunches, guesses, judgements, non mathematical conjectures, let alone ideas based on constructs are not, are not, hypotheses, according to the common, accepted and acceptable definition of Scientific Theory. Period…

    That is pseudoscience, having two dowsers, two quiromancers, etc., trained to agree with a set of “findings” to make a claim, a prediction, does not make it even science prone…

    The example of the N-rays, and I guess others make that relevant to scientific research in real scientific fields, not the humanities. Humanities are not sciences even if they do empiricism… and have constructs. Period…

    I am suprised the quoted paper does not mention scientific theory, but does speak of science, pfuff!, what an omision!.

    And sadly, aparently the typist with ideas, after all written in that piece alone, still has hope?, faith?, something else? in psychiatry!?. Explainable since psychiatry, as it wrote, as I understand, claimed started from beliefs… which lead to misunderstandings, acrimonious disagreements, delusions, hope, faith, dogma, etc. That thorougly, I guess, as an opinion, explains the skirmishes in the succeding editions of the DSM.

    And the claim of pragmatism, ahhh, pragmatism, the flock can’t loose faith and income… they can’t wander into their own knowledge and judgment, it is heretical… schismatic even…

    Such centuries old parallels, that smell of analogies, metaphores, humm…. but may be more like rhetorically, logically caused by being human in a field with no Scientific Theory. Or not?. I am not claiming empirical backing for this assertion…

    Why don’t all wrokers involved in such activities, do the world a favor and either start looking for facts, scientific facts and claims, or else do something else with their training that does not involve psychiatry?. Hum?, why?, what non-Freudian psychodynamic, belief or motive drives them to keep pursuing something, a New State of the Art, that is not 40yrs old, but at least 100-200yrs old?. This New came as Old as the Old one, paraphrasing a mexican joke… “Este hombre nuevo te salio tan alcoholico como el otro”.

    Calling judgement and research usefull to diagnose and treat patients as cardiologists or surgeons do, is a severe misunderstanding or misstatement, in my opinion. Said folks can prove a coronary blockage, they can send a grangrened limb to the pathologist, etc. Psy wrokers can not do that, saying someone improved is riddled with confusion factors, unfalsifiable, unempirical (no causality can be tested), etc.

    That is not only pseudoscientific, but stinks, not only smells, as my opinion, of bad faith, fraud, ill-will, sociopathy, or lack of otherwise marketable labor skills…

    I am not making claims, I am only making metaphors and analogies to other activities imputed thus…

    Maybe the refered author will turn fully heretical?, marry a complementary, however defined, gendered monk, and tell us of his or her wrongdoings, in full detail, while in the “temple” of Psychiatry?. Or is that another more contemporary parallel?. Persecution?. Hum?. No tattle tellers?, no whistleblowers?. No community of escaped believers to help another evade the wrath of the establishement?.

    I invite the text maker of the linked piece thus, after carefull lawyer consultation. Otherwise, whatever criticism he or she does of the creed, gospel, or as phrased: belief, is beyond disingenous, to me, as my opinion.

    I find it not offensive to my knowledge or inteligence, whatever remains of them, but to my, ironically, gullibility…

    Weez, what contortions of language to say something that was written more plainly…

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  4. Another claim that is obviously surprising in a bad way, an inference actually, is that the text maker seems to think of itself as better than the cabal writting the DSM, without going claim by claim to prove that.

    Withouth disproving diagnosis by diagnosis, claim by claim the whole of the DSM, just empty and not landed cuasi-arguments, to claim it is merely administrative. Based on his or her reading/take of DSM history alone.

    The text writer seems to be questioning the authoritative quality of the DSM by narrating a view of DSM history without doing the grunt work… kinda lazy and self serving in a prejudiced/biased way.

    And that the text maker’s clinical judgement and psy magazine reading knowledge somehow is way better than that of the writers of the DSM, for the whole thing, not just a niche, pet interest…

    That is not bold, but sounds to me reckless and quite grandiose, almost delusional. Some psy believer might say it reflects, uuugh, “poor judgement”, ironically*. Aggregating, manic/hypomanic even, but I am not diagnosing, just literary fluffy cheek puffing… for comedic effects…

    To prove it delusional, as the definition of delusions requires, all it would take is to ask the text maker to please annotate the whole DSM with his/hers counterclaims, and allow the writers of the DSM to counter-counterclaim, and so forth. If it cannot do that, then delusion is almost a given, if the text maker persists.

    But, the text writer is not doing that, the, I especulate, intent is to impress the patients or future patients with “critical thinking”, when said individuals can’t provide rhetorical force as the DSM authors probably could. Pick on the little fellow, impress him or her with your “deep” knwoledge sort of thing.

    Or else, an out of delusional jail card, do what I did, take the scaffold of the DSM and prove it is illogical, in toto, not piece by piece. I can look grandiose too!, and I am certainly not bipolar…

    Or at a minimum, unlike apparently, I can claim I am not lacking, uuugh, insight*…

    *That’s a problem with there is a symptom label for any expression of behaviour, labeling abounds, ignorance and confusion deepen, etc. I am merely trying to turn the tragedy of implementation of the psy disciplines, it’s spillage outside the field of contructs where it belongs, to make comedic exposure…hehe…

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  5. Now, still me flowing along the comedic river, I am going to put a set of premises, NOT claims, without giving an argument, yeeweez, I write so profesorial!.

    1.- As per the DSM it is authoritative and the best there is.

    2.- The DSM is a set of constructs created with the intent to be instantiated in individuals, i.e. to make diagnoses.

    3.- There is at least one claim, the linked text maker one, that it is not the best set for that, there is at least another better set of constructs: his or hers. And by recommendation, each practitioner has a better set of constructucts, if, if, he or she uses his or her judgement and reading psy magazines.

    4.- A set of sets is still, or itself a set.

    5.- The set of individual psy practitioner’s constructs is still a set, a set of sets of constructs. That is: the aggregate of individual practitioners beliefs about mental disorders is an aggregate of the constructs residing in their own minds.

    Undefined yes, but in the abstract, as a construct, IS, in the metaphysical/ontological sense… it does not exist, in the real world, unless each practitioner puts it in writting, as in the DSM… I want to see that!. There were enough squabbles in most DSM revampings…

    6.- Well, sorry to say, according to 1, that can’t be the best set of constructs there is. Period…

    And that contradiction actually makes all psy practice irrational, precisely because the way the DSM is written: collegially by top experts with FEEDBACK, presumably from the set of constructs in individual practitioners outside? the DSM clan/clique, outside “La Banda”, in spanish.

    Regardless of it’s history, if they, top expertly, collegially and with FEEDBACK can’t do better now, how could any practitioner do it better?. Alone? without peer review?. That looks like a reductio ad absurdum…

    Why?, precisely because the DSM is already a set of sets written by experts in each category, in each diagnosis. It was made with the same tools, knowledge, biases, interests, motives, HISTORY, limitations, etc., as exist, yes presumably, for each and every other practitioner. No black swans or “enlightened” pracititioners assumed, or implied. No uber genius either.

    No book of proof for psy disciplines, as erdos showed convincingly exists for mathematics: “The Book”. Capital e, but well…

    Claiming 5% of the DSM might be the best set of constructs and the other 95% is of fabricated/false ones does not make any practitioners set of constructs better than the whole of the DSM. Same incentives b,r,o,h…

    It is a false hidden premise, since it has not been proven, and there is due skepticism that it can be done at all.

    It questions the authoritative quality of the DSM without establishing MORE authority to do that, a fallacious appeal to authority, going both ways, sort of thing.

    In common sense words: why would any set be better when the DSM authors also use clinical judgement and reading psy magazines?. Wasn’t it bad enough?. Using the constructs in the mind of an individual practitioner when seeing an individual patient does not, DOES NOT, obviate the need for constructs to do THAT!. In the psy disciplines that is, other folks have facts, scientific facts for that.

    7.- Using individual practitioners judgement and psy magazine reading replaces a defined set, the DSM, by an undefined set: the minds of ALL practitioners. How is that an improvement?. How could that be NECESSARILY, FORCEFULLY, better?. Hum?. The text maker of the linked article does not say, let alone prove how…

    8.- When it comes to theory, models, whatever, replacing a defined one for an undefined one is BAD. It is what could be called irrational.

    Replacing written “rules” with unwritten ones in algorithmic procedures is beyond belief in any science, in any logical exercise… Or is psy diagnosis not algorithmic?. If this then that, if not that then not this?. Does not work like that?.

    If refered insominia, then could be A, B, C or D, then if A, E should be present, if not then, if B present then F should be present, kind of thing.

    So, to land on relevance: the proposal for each practitioner to do better than the DSM, as in the text makers linked article, is proposing an irrational thing, and contrary to common sense.

    It is dangerous, and probably reckless, since it is applied, instantiated to people, humans, that will suffer the consequences of said irrationality. And apparently lack of common sense.

    You know, experts of irrational, pseudoscientific, cuasi-intellectual activities… “reasoning”, using judgement!, yeepee!, with unwritten, non-peer reviewed constructs…

    Cardiologists and surgeons are supposed NOT, NOT to do that!.

    So much for reading peer reviewed psy magazines, then to be replaced by unwritten non-peer reviewed “constructs” (in tiny, soft, almost mousy squibbly voice).

    QED.

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  6. Now, finally, hopefully, my last on this linked piece of propaganda looking stuff faking criticality:

    Mr. Ghaemi, ejem, if your judgement and reading of psy magazines is better than the DSM for diagnosing YOUR patients, please write your constructs, published them in peer reviewed journals and then, and then, and only then, get them incorporated into the DSM. That way at least I can believe your assertions…

    As for an attempt at full disclosure, I am passing the invective I got from another physician to you, when I actually was right, may the force prove you right too!.

    I hope you can excuse my, not trauma, but impression, as in impressionistic endeavour of educating physicians, senior ones like yourself, from my low standing, admitedly small position, in the medical comunity, then and now.

    🙂

    It’s just for fun, tragedy in the psy disciplines is bad enough.

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