DSM-V: Part 2--What's a brain disorder?

Should it be what the DSM says it is?

The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been coming out since 1952 and has changed dramatically since then. “Human nature has not metamorphosed but each DSM has included more disorders than the last,” writes Frederick Crews in NY Review of Books (Dec.6, 2007). By the fourth edition in 1994, (which some of us were fed on like mothers' milk), there were over 350 disorders listed, “marked by dubious symptoms such as feeling low, worrying, bearing grudges, and smoking.” Those items were put in checklists so that “in Bingo style, for example, a patient who fits five out of the nine listed criteria for depression is tagged with the disorder.”

Christopher Lane, a literary critic and not a psychiatrist, who follows the Freudian line (and hated that the third edition abolished the neuroses), opposes the attempt in these volumes to categorize disorders according to their “detectable traits”. He writes that the DSM has ended “almost a century of psychoanalytic thought and (is) thus a reversion to Victorian psychiatry.” (I think he means in Victorian England these disorders were thought to be morally corrupting and curable, and so they put people away, which led to the way mentally ill people were treated in our country until the 1960s and '70s.)

What is a mental disorder? Well, here's the way the current manual, the DSM-IV-TR, puts it: “While this is a classification of mental disorders, no definition adequately specifies precise boundaries for the concept of a mental disorder. (They) have been defined by a variety of concepts, e.g., distress, dysfunction, dyscontrol, disadvantage, disability, inflexibility, irrationality, syndrome pattern, etiology and statistical deviation. Each is a useful indicator but none is equivalent to the concept and different situations call for different definitions.

“The DSM-IV uses categories to divide mental disorders into types based on criteria sets with defining features,” it continues. “That's the traditional method of organizing. (But) there is no assumption that each category of a mental disorder is a discrete entity with boundaries dividing it from other mental disorders. There is also no assumption that all individuals having the same disorder are alike in all important ways.”

With this much leeway to go on, no wonder the critics are having a field day. As one writer points out, “the rapid pace of pharmaceutical innovation has resulted in a corresponding need for the discovery of new diseases as well. As long as the drug industry continues to develop new products, the American Psychiatric Association guarantees a steady supply of new diseases requiring treatment.” And these find their way into the DSM. There are “diseases and subcategories, co-morbidities, prodromal forms of combined clinical subtypes, shadow syndromes and the like. ..(also) the catch-all category known as Not Otherwise Specified, or NOS, which is applied whenever the symptoms of any given mental disorder do not meet the criteria of any specific disorder within that category.” (bonkersinstitute.org)

Every new disorder is supposed to meet a host of criteria before being accepted into the manual. But transparency is a big issue and “behind the dispute is the question of whether the vague, open-ended terms being discussed even come close to describing real psychiatric disorders,” writes Lane in the Los Angeles Times. One of the past consultants to the DSM, he says, has revealed that editorial meetings over changes “were often chaotic. There was very little systematic research.” And the main author of the previous volume, Robert Spitzer, said he's against science by committee because of the willy-nilly way that psychiatrists have defined dozens of disorders in the past.

There is suspicion, too, that industry profit motives are bound to influence what goes into the DSM. Lane's book, “Shyness,” exposes efforts of the big drug companies to have shy people view themselves as mentally ill. He cites “the manipulations that promoted social anxiety disorder to a national emergency,” created by Madison Avenue and Big Pharma that have led to billions in profits for the companies. An ad for Zoloft in the American Journal of Psychiatry, August 2003, for instance, shows a woman with downcast eyes and asks: Is she just shy? Or does she have social anxiety disorder?

Sadness is another trait that is focused on. In “The Loss of Sadness,” Allan Horwitz and Jerome Wakefield comment on the fact that depression is now declared epidemic around the world by the World Health Organization. “Those judgments rest on failure to distinguish between major depression, indeed devastating to its sufferers, and lesser episodes of sadness, they argue. “Episodic sadness has always been a socially approved means of adjusting to misfortune and much is lost, both medically and culturally, when it is misread as a depressive disorder.”

The book implies that nearly every non-psychiatric complaint is subject to over-diagnosis unless contextual factors—familial, cultural, relational, financial—are weighed in the balance.” The authors beg the compilers of DSM-V to inquire into each patient's circumstances before concluding that they are faced with a bona fide disorder. But as author Crews points out, the DSM's inability to separate “vague discontents from real maladies” serves the profit making purposes of the medical profession and isn't likely to be changed. (Roy Neville)