DSM: ‘Bible’ or a ‘true’ Apocrypha?

The first two weeks of the month of
February were abuzz with the news — carefully rehearsed and
timely released by the American Psychiatric Association (APA) —
that advanced "beta" copies of the forthcoming final edition of
DSM-V were up for sales and evaluation.

In preparation for their most recent "Big
Bang" the APA offers a website where the various proposed new
diagnostic categories, being considered for inclusion on DSM-V,
are listed for review, suggestions and/or comments.

Apocrypha

The following is what you will find if you
visit this site:  www.dsm5.org.

Proposed Draft Revisions to DSM Disorders
and Criteria 

The draft disorders and disorder
criteria that have been proposed by the DSM-5 Work Groups
can be found on these pages.  Use the links below to read
about proposed changes to the disorders that interest
you.  Please note that the proposed criteria listed
here are not final.  These are initial drafts of the
recommendations that have been made to date by the DSM-5 Work
Groups.  Viewers will be able to submit comments until April
20, 2010. After that time, this site will be available for
viewing only.

The important thing at this point is that
numerous clinicians have begun capitalizing in the pre-sales
"fever" for this manual, having published numerous books that
portend an enormous success for this so-called "Bible" of the
psychiatrists.

Redoubtable "bible"

Our position and
reasons to be skeptical with all the hoopla

Over the years we have leveled criticisms
to all the previous DSM-ETC manuals, aiming our attacks
specifically at the most current, DSM-IV, which under the
direction of Robert Spitzer became a forerunner of the future
bulky manual, whose dimensions will expand, no doubt, to meet the
requirement of the moment.

The history of
DSM-ETC

As an idea, DSM-I was published for the
first time in 1952, sponsored by the APA.

It consisted of an adaptation of a previous
classification adopted in 1918 by the US Census Bureau for its
internal use, for the use of the government psychiatric hospitals
and for its application to the branches of the military medical
services.

DSM-I then, only had 130 pages, and 106
diagnostic categories.

DSM-II made its debut in 1968, with 182
listed diagnostic categories in 134 pages.

Up until then, both manuals revealed the
hegemony of the hold that at that at the time, psychoanalysis had
on American psychiatry.

In both manuals symptoms did not receive
special attention as part of specific disorders, being considered
as mere faulty adaptations to the demands and realities of
everyday living.

These flawed adaptations were distinguished
among them in terms of severity, establishing progressive
gradations in a continuum from mild neurotic symptoms to
psychosis at the end of the line.

In other words, mental illnesses were one
and the same in a matter of gradations.

Despite the inclusion of biological and
psychological elements, the schema proposed by DSM resulted in a
model that failed to delineate with any precision the differences
that exist between abnormality and normalcy.

In 1974, the decision was made to make a
new revision of DSM and Robert Spitzer was chosen to lead the
Task Force.

The initial idea was to make the US
nomenclature consistent with ICD (International Statistical
Classification of Diseases and Related health Problems),
published by World Health Organization (WHO).

WHO

But, under Spitzer steering, the Project
acquired a much broader purpose and a more ambitious
goal.

From its inception the objective of
improving the reliability of psychiatric diagnosis was
established, since the different diagnostic categories between
professionals and countries were different.

Similarly, an effort was made to turn DSM
into a "research" tool.

For the latter purpose a multiaxial system
was introduced, as part of a project aimed at making a more
accurate determination of the patient"s condition, instead of
limiting the scope of diagnosing to a simple formulation with the
resulting label.

Another objective consisted in making the
diagnostic formulation based on description, with a total
exclusion of the psychoanalytic model in favor of a biomedical
mold, wherein the interfaces of what"s normal and abnormal are
differentiated.

The criteria adopted for the definition of
many psychiatric disorders were adapted and amplified from the
RDC (Research and Diagnostic Criteria) of John Feighner
et al. formulated at Washington University in St. Louis, already
in existence since the 1970s.

It was not a peaceful period for DSM and
its new architects. Many internecine territorial fights were
contested in silence, between those who were trying to appease
the various contending camps in psychiatry.

The major hurdle was created by the
outright elimination of the concept of neurosis, which forms a
cornerstone of psychoanalytical theory.

In many ways resemble the various churches
struggling to maintain control of the dogma for themselves
alone.

And in that particular sense DSM is a
"bible", because is based more on faith than science.

A final compromise was able to arrange a
truce, and the hostilities ceased through some accommodations
achieved discretely by means of the application of euphemisms
between parentheses, modifying some conflicting or controversial
categories.

Finally, DSM-III was published in 1980,
with a growth to 449 pages and containing between its covers a
list of 256 diagnostic categories.

Although our species had not undergone
tangible mutations, the mental illness that feed on us have grown
and multiplied, perhaps as result of biblical
inspiration.

DSM tremendous circulation was amazing and
for many of their devout enthusiasts and apologists qualified as
a "true revolution" in the field of psychiatry.

Enthusiasm that later proved exaggerated,
premature, and — more than anything else —
unwarranted.

In 1987 DSM-III-R was published as a
revision of DSM-III, under the direction of the indefatigable
Robert Spitzer.

In this new edition many categories were
reorganized, others received new names, and significant changes
in all the diagnostic criteria were implemented.

Six categories were disposed off and new
ones were added.

Some controversial labels — as were
dysphoric premenstrual disorder and masochistic personality
disorder — were discarded among the notable modifications
made.

Now, DSM-III-R boasted 292 diagnostics and
567 pages of text.

DSM-IV

DSM-IV was published in 1994, with 297
diagnostic categories contained in 886 pages.

Now the Task Force had a new chairman in
psychiatrist Allen Frances.

An Orientation Committee was installed made
up by 27 persons, including four clinical
psychologists.

Of singular importance in this stage was
the new requirement that the diagnostic categories had to
establish, as part of the assessment, the degree of disturbance
any condition caused on the occupational, social and other
significant areas of the patient"s functioning.

True psychiatric diagnosis

In the year 2000, a text revision was
completed, today known as DSM-IV-TR.

The diagnostic categories remained intact.
The only major progress was in trying to maintain consistence
with ICD.

DSM: Homosexuality as
a diagnosis and the politics of psychiatry

During the years 1972 and 1973 gay
activists protesting the inclusion of homosexuality in DSM
targeted for disruption the annual APA conferences, creating so
much havoc that the objective they were after was thoroughly
achieved.

Talk about fighting for one"s convictions
and for what"s deemed right and correct

Then DSM-II promptly excluded homosexuality
as a diagnosis, evolving to what today is known as "sexual
disorder not otherwise specified", category that stresses that
the victim suffers "persistent and pronounced anguish about his
sexual orientation".

So much for that, as a wishy-washy
compromise and an erroneous assumption.

Understanding
DSM-IV

DSM-IV is a classification system based on
the use of categories. The categories themselves are prototypes,
so that a patient that approaches any one prototype is considered
victim of the disorder to which he comes close.

DSM-IV establishes that "there are no
conjectures that each category of mental disorder is a complete
entity well delineated and delimited with precise
characteristics…"

But, despite the grandiose and
unsubstantiated assumption made in the above paragraph, it goes
on to admit that overlapping may exist between
categories.

Qualifiers are used with inordinate
frequency determining mild, moderate and severe forms in each
diagnostic category.

The interference with the individual normal
functioning must be specified in detail; although this
requirement has been eliminated from the tics and some of the
paraphilias.

Each category has a distinctive number that
qualifies it for (the most important requirement) the use by
medical insurers and for "administrative purposes" whatever that
might mean.

Psychiatric diagnosis

The multiaxial
system

DSM-IV organizes each diagnostic group
within five tiers or axes that relate to different aspects of the
disorder and its impact on the individual.

Note: Because this classification can be
obtained with relative ease from many internet sites, we will not
provide the reader with a detailed description of the
axes.

Warnings

The APA is eager to instruct those who get
their hands on this — their "Bible" — that these manuals were
not published for the uninitiated or for the general public, but
that they were intended to facilitate the labors of specialized
professionals in the sciences of human behavior.

Warnings about the
warnings

While the APA gives us its well intended
caveats about the use of the manual, at the same time continues
promoting its sales for the use of all kinds of professionals and
for all kinds of purposes, some of them quite controversial as we
will see later.

As it happens with the other — the "real"
Bible — the one the clerics and their colleagues of the cloth
use, one must be supervised to read what, in essence is a rather
simplistic and mechanical manual.

See how some might use it

Dr. Edward F. upon seeing his first
anorexic case that I referred to him, casts a word of doubt as to
the correctness of the diagnosis.

Here are his reasons, armed with
DSM:

"She did not pass the DSM test. I asked if
she had a distorted body image and she said no to this

"Then I asked if she used denial in her
situation and she also said no

"I think she is faking it".

They also have an important analogy to
make, and that is that the manual is not to be used as a
cookbook, although it is written as such.

Psychiatric diagnosis

But with the publication of the manual,
unlike what happens with the Bible, the matters of dogma are
never settled, and new sales begin.

In addition to the manual, the APA
publishes four sourcebooks that serve the purpose of lending some
needed scientific semblance to their manual.

Future plans already envisioned for
DSM-V

The new "bible" in the current vernacular,
is programmed to appear in 2012 or 2013.

Meanwhile six different groups are at work
in its perfection, with other side groups also involved to
achieve the final objective and structure.

Detailed descriptions of the role and
functions of these groups are contained on my various articles on
the subject.

Criticisms of
DSM

A literature review and visits to some
internet sites reveal that DSM, despite its relatively good
standing, does not receive much endorsement or support from some
important detractors.

Here are some of the main
criticisms:

• That the diagnostic validity of DSM-IV
  categories are exaggerated and lack documentation

• That as a system makes distinctions
  between the various categories that are not factually
  supported

• That the application of a diagnostic
  system based on a compilation of symptoms leaves outside the
  scope of its considerations important details about the
  understanding of the individual patient (vide supra the case
  of Dr. Edward F.)

• The political aspect of DSM presents an
  important argument by itself, specifically its use and
  applications by medical insurers and drug manufacturers. The
  conflict of interests is a matter of the greatest importance,
  since more than 50% of the professionals active in the
  structuring of all DSMs since their inception maintain close
  ties with the companies that manufacture pharmacological
  agents for use in psychiatry.

Recently there has been a deluge of
reactions that originate from respected academics who seriously
doubt the value and relevance of DSM in all its permutations and
forms.

Psychiatric diagnosis

Proceeding with this thesis

In order to maintain themselves current and
viable, the architects of DSM-ETC have to reinvent themselves,
that"s the reason why I use "ETC" to qualify the number on its
editions, because we can expect that it will be revised for as
long as there are buyers.

And buyers there will be, for as long as
the "bible" can be pressed to serve their goals.

Let"s take two diagnostic categories
creating teacup storms ahead of DSM-V.

The families of children victims of
Asperger"s who want their category to remain included so that
they can continue to derive, otherwise withheld insurance
benefits, and the new champions of orthorexia that are anxious to
have healthful eating included as a diagnosis.

But, let"s examine one of the current
diagnoses included under the rubric of eating
disorders.

We are referring to the melodious sounding
EDNOS.

Here is what"s all about:

Ednos. In the current edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV),
it encompasses virtually every type of eating problem that is not
anorexia or bulimia.

Psychiatric diagnosis

Though its name is less familiar, it is
diagnosed more often than those two disorders — in 4
percent of American women each year, according to the National
Eating Disorders Association. (The association does not have
statistics on men.)

Subsets of Ednos include binge eating
disorder, purging disorder, night eating syndrome, chewing and
spitting out food, and even picky eating.

But the diagnosis baffles many clinicians,
who call it ambiguous, vague and unwieldy. And so the American
Psychiatric Association is overhauling its definition of Ednos
for the next edition of the diagnostic manual, known as DSM-V, to
be published in 2013.

"The consensus is that Ednos is "too big,"
meaning it is being used more frequently than is desirable, as
that label does not convey much specific information," said the
chairman of the eating disorders work group for the new
manual.

Adding, the panel was "considering a range
of ways to reduce the frequency with which that very broad
category is used." For now, though, Ednos remains as the nation"s
most common eating disorder. A September 2009 study in The
International Journal of Eating Disorders found that Ednos was
often a way station between an eating disorder and recovery or,
less commonly, from recovery to a full-blown eating
disorder.

While traveling with a scale in your
backpack is not one of the criteria, preoccupation with weight
and food is. So are severe chronic dieting, frequent overeating,
night eating syndrome, purging disorder and possibly compulsive
exercising.

Psychiatric diagnosis

If all that sounds a little vague —
find one woman who isn"t preoccupied with her body size —
psychologists make a distinction.

"The eating has to be disordered in some
way, as does the behavior relating to eating," said a
professor of psychology at Montana State University. "Also, it
has to lead to some kind of impairment. For instance, some women
will not go to parties because they"re worried about
eating.

"If you"re restricting yourself so much
that it affects your work negatively, you would meet the criteria
for Ednos."

Even so, many clinicians say the diagnosis
is just too roomy.

"One of the difficulties with Ednos is that
there"s a lot of diversity within that category," said another
expert, director of an eating disorders program.

"Because there are different presentations
that not all clinicians are familiar with, there"s a risk that
people who have disordered eating who could benefit from clinical
attention won"t know that they have a problem."

Indeed, one reason the panel wants to
change the guidelines is to help patients with eating problems
recognize them even if they do not exhibit any of the traditional
symptoms.

So that they direct their attention to seek
reimbursement for "treatment" or for "medicines to cure
it".

Kris, for example, used laxatives and
restricted her food for years, but she never threw up or binged,
and her weight was average. She did not seek psychiatric help for
what she and her husband called her "eating problem" until age
31, when she became addicted to the diet pill ephedra, she said
in a recent interview.

Psychiatric diagnosis

Now 37 and the director of a child care
center in Atlanta, Kris said that when she finally got her
diagnosis of Ednos, "it was like, Ah, I am sick enough
to get help and have the recovery experience." 

Most health insurance policies do not cover
Ednos. (Kris refinanced her home to pay for her
week-and-a-half-long stay at a residential treatment center.) Yet
people with it are at risk for many of the same medical problems
that afflict anorexics or bulimics, including osteoporosis, heart
attacks, hormone imbalance and even death. A study in the Oct. 15
issue of The American Journal of Psychiatry reported that the
mortality rate associated with Ednos exceeded that for anorexia
nervosa and bulimia.

Not due to severity, but due to the greater
frequency with which Ednos is now being applied.

With that in mind, many doctors blur the
diagnostic lines just so their patients can get insurance
coverage. A chewer and spitter might be classified as bulimic,
another expert said; an almost-anorexic would fall under binge
eating disorder.

Clinicians say patients like these often
need to feel they have a "real" eating disorder.

A great number of patients feel this stigma
if they know they"re diagnosed with Ednos: "Obviously, I"m not
good enough to be anorexic," said another expert consulted.
"I"ve had many patients feel that they need to lose more weight
so they lose their period so they can change the diagnosis.
Patients really feel they have to get "better" at their eating
disorder to deserve treatment."

That is how Stacey felt. Stacey, 26, a
prekindergarten teacher in Alexandria, LA, said she had been
dieting since age 7; at 16, she lost 70 pounds, and from then
until age 25 she purged and abused diet pills, diuretics and
laxatives. Although she vomited 3 to 11 times a day, she was
never classified as bulimic because she did not binge, and her
weight was never low enough to be anorexic.

Psychiatric diagnosis

"The doctors would look at me and say, "You
don"t look like you have an eating disorder — go home and
get something to eat," she recalled, adding that she didn"t
think she was "sick enough" to need help, either.

Some doctors say weight requirements should
be eliminated from all eating disorders in the new diagnostic
manual. Deb, an eating disorder specialist in Los Altos, CA,
notes that people of any weight and body mass index may binge,
purge or diet excessively.

"I have worked with plenty of restricting
average-sized and fat patients who really should be diagnosed
with anorexia nervosa," said Deb, a founder of a program, an
approach that focuses on health rather than weight. "But there is
confusion based on the current DSM whether they meet the criteria
for the diagnosis if they are not at a low BMI. — even if
their current weight is extremely low for them individually and
they"re showing signs of starvation."

Perhaps the most difficult part of treating
Ednos is that "normal" eating is such an elusive concept.
Thinness tends to be the ideal, no matter what lengths people go
to get there.

"What Ednos really demonstrates," said
another specialist "is that we don"t have empirically derived
diagnoses in psychiatry".

Psychiatric diagnosis

"Think about the diagnosis of depression.
When does someone have a clinical syndrome versus a mood
fluctuation? At what point should it be regarded as a condition
that needs treatment? When you talk about food habits, it becomes
extraordinarily complicated, because everybody has a relationship
with food, and it"s usually a somewhat complicated
one."

Observations

Ednos, is NOT a diagnosis, but another
expression of the tremendous power DSM-ETC can exert when
inventing new categories.

Under Ednos, a post-op gastric reduction
patient, with more than 25% loss of body weight, would qualify
for anorexia, a vegetarian would qualify as "orthorexia" for
avoiding hamburgers, as it would do the same, people who keep
kosher or those who insist in not eating fat and sugary foods
because they are fattening.

In other words, everybody will qualify,
while the drug companies will release products to match all the
new categories.

The diagnosis in psychiatry

When I entered the field of psychiatry in
order to establish a diagnosis we were guided by that, the most
valuable of instrumental tools developed in
psychiatry:

The Mental Status
Examination (MSE)

In order to be fair and eclectic, before
going any further I"ll offer to the reader an abridged summary of
what Wikipedia English has to offer as definition:

"Theoretical
foundations

"The MSE derives from an approach
to psychiatry known as descriptive
psychopathology or descriptive phenomenology which
developed from the work of the philosopher and
psychiatrist Karl Jaspers. From Jaspers' perspective it
was assumed that the only way to comprehend a patient's
experience is through his or her own description (through an
approach of empathic and non-theoretical enquiry), as
distinct from an interpretive
or psychoanalytic approach which assumes the analyst
might understand experiences or processes of which the patient is
unaware, such as defense mechanisms or unconscious
drives.

"In practice, the MSE is a blend of
empathic descriptive phenomenology
and empirical clinical observation. It has been argued
that the term phenomenology has become corrupted in
clinical psychiatry: current usage, as a set of
supposedly objective descriptions of a psychiatric
patient (a synonym for signs and symptoms), is
incompatible with the original meaning which was concerned with
comprehending a patient's subjective
experience.

"Application

"The mental status examination is a
core skill of psychiatrists, nurses, and other qualified mental
health providers. It is a key part of the initial psychiatric
assessment in an out-patient or psychiatric
hospital setting. It is a systematic collection of data
based on observation of the patient's behavior while the patient
is in the clinician's view during the interview. The purpose is
to obtain evidence of symptoms and signs of mental disorders,
including danger to self and others, that are present at the time
of the interview. Further, information on the patient's insight,
judgment, and capacity for abstract reasoning is used to inform
decisions about treatment strategy and the choice of an
appropriate treatment setting. It is carried out in the
manner of an informal enquiry, using a combination of open and
closed questions, supplemented by structured tests to assess
cognition. The MSE can also be considered part of the
comprehensive physical examination performed
by physicians and nurses although it may be performed
in a cursory and abbreviated way in non-mental-health
settings. Information is usually recorded as free-form text
using the standard headings, but brief MSE checklists are
available for use in emergency situations, for example
by paramedics or emergency
department staff. The information obtained in the MSE
is used, together with the biographical and social information of
the psychiatric history, to generate a diagnosis, a psychiatric
formulation and a treatment plan".

Psychiatric diagnosis soon to be in
exile

That is a definition as good as any one may
need for any purpose

For my convenience, while serving in the
Navy, I abbreviated the essentials of the format as
follows:

• Orientation

• Memories

• Intellectual resources

• Judgment and

• Affect

That"s was it! (OMIJA).

It served me well — very well.

Now, that was before I realized what my
supervisor Louis F. Cleary, was trying to tell me, when advised
me of the following:

"The psychiatric diagnosis is an intuitive
exercise that only those who are able to master it can
appreciate.

"It"s usually done during the first few
minutes of the interview with the new patient, the rest of the
session is used merely to confirm your impressions

"But, the most important thing to bear in
mind is that is an ongoing and dynamic process that one has to
review constantly during therapy".

The latter summarizes the old idea that
some doctors were naturally endowed with a clinician"s eye. (Eye
of Horus?).

Psychiatric diagnosis in the
offing

And I can attest to the accuracy of my
beloved teacher"s observations.

Is nothing like my friend Edward attempted
to do with Carolynn (the name of the anorexic patient whose
diagnosis he entirely missed).

But, that"s not where the perils of the
diagnosing by criteria end.

This "shopping list effect" can be used
with devastating consequences in a court room by unscrupulous
attorneys and psychiatrists that adjust their diagnostic
formulations following the bed of Procrustes that DSM so nicely
avails to them.

In a particular case, an attorney for the
defense in a case of admitted wrongdoing by the client. The
agitated attorney brandishing a copy of DSM, to which she pointed
with her finger furiously, attempted to demolish the well
established formulations concluded by the expert witness, by
demanding an item by item justification for his
impressions.

DSM is based on biased reasoning and
nothing else.

But is it patterned after a recognizable
model?

If check lists can be models, perhaps it
is, but before we answer that question, let"s see the most likely
to be the model that any system of classification should
follow.

Let"s see what the science of taxonomy has
to offer on this regard.

After a very thorough review of much of
what, about this is written, I am left with the uncomfortable
feeling — and feelings are not precisely the stuff of
scientific inquiry — that what the architects of DSM-ETC really
desired to achieve was to install their Procrustean bed at the
side of the road of psychiatry as a discipline and for them to
adjust the bed to fit their personal agendas.

Thus, by adopting something as subjective
as their whims would have it and as subversive as the needs of
the occasion would require, everything would result in what we
already have; a system that is absolutely unsystematic and an
unscientific "scientific" instrument to classify the morbidity of
an entire field of endeavor, namely the field of
psychiatry.

All about Big Pharma

The shortcomings of all DSMs have been
proven through the years of their existence.

But, as the Politburos of the ancient
communism would have it, it can be very effective in establishing
political control.

In this case, the losers are American
Psychiatry and the American public, for having no one whom to
trust…

I rest my case.

Bibliography

Ample references furnished on
request.

Autor:

Félix E. F. Larocca
MD