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Infallibility and Psychiatry's Bible

The latest "Diagnostic and Statistical Manual of Mental Disorders" is being revised and, by some, reviled.
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"For every ailment under the sun/There is a remedy, or there is none/If there be one, try to find it/If there be none, never mind it."

Imagine how easy the practice of psychology would be if we lived in the black-and-white world of Mother Goose. Alas, resolving the many pathologies amid the vast spectrum of human behavior remains in many cases elusive, despite myriad treatments and interventions available today.

Still, the path to wellness would be near impossible were it not for the Diagnostic and Statistical Manual of Mental Disorders. This encyclopedia of mental illness, published by the American Psychiatric Association, offers the final word on everything from kleptomania to schizophrenia. No wonder it's regularly consulted by clinicians, health insurance companies, the pharmaceutical industry and policymakers throughout the United States and, in varying degrees, the rest of the world.

The latest battle became public last summer when the authors of the current DSM-IV, Allen Frances and Robert Spitzer, sent a letter to the APA's Board of Trustees warning of serious problems with both the process and content of the DSM-V, currently being revised for publication in 2013. Their missive followed a back-and-forth between Frances and the APA in the pages of the Psychiatric Times.

In their July 6, 2009 letter, Frances and Spitzer assailed the DSM-V task force for its lack of transparency: "The DSM-V leadership has lost contact with the field by restricting the necessary free communication of its workgroups and by sealing itself off from advice and criticism." Unless the internal review process improved, the authors warned that questions would be raised about the "legitimacy" of the APA's role in producing this and future manuals.

A series from on the controversy surrounding the latest Diagnostic and Statistical Manual of Mental Disorders:

Part I: Infallibility and Psychiatry's Bible (May 25)
Part II:Who Benefits? DSM Conflict of Interests (June 3)
Part III:Are You Normal or Finally Diagnosed (June 8 )

Perhaps more disturbing, especially to the general public, was Frances and Spitzer's assertion that thanks to new thresholds for defining mental illness, tens of millions of "false positives" — otherwise known as people — will become newly diagnosed patients "subjected to the needless side effects and expense of treatment."

All of this is complicated by medicines that may not do what they promise to. (A recent article in the Journal of the American Medical Association, for example, found that antidepressants were no more effective than sugar pills for individuals suffering mild to moderate depression.)

Frances knows the problem all too well. As the former chair of the DSM-IV task force, the 57-year-old Duke University professor of psychiatry contributed unintentionally to some of the most popular over-diagnoses involving children.

"I'd been party to three false epidemics, ADD, autism and childhood bipolar, thinking that I'd been very careful," Frances says. "I had realized that no one else would be in a position to know how damaging it could be as someone who's already contributed to the problems. If we could be conservative and careful and do this, a group that wants to be ambitious and that is less careful could do much more damage."

This did not sit well with the APA, which responded with a counterattack. In the Psychiatric News response, APA President Alan Schatzberg said that Frances "misrepresented" the information presented through DSM-V updates as final products rather than works in progress.

Moreover, Schatzberg hinted that Frances and Spitzer were questioning the DSM for their own financial gain. As Schatzberg wrote: "Both [Frances and Spitzer] continue to receive royalties on DSM-IV-associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV-associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing."

Both doctors reject Schatzberg's charge and continue to speak out against the direction the new DSM is headed. Three days after the much anticipated (and delayed) publication of the DSM-V draft proposal on Feb. 8, Frances wrote another commentary for Psychiatric Times, "Opening Pandora's Box: The 19 Worst Suggestions for DSM-V." Just how much an impact all this internal feuding will have on the final product remains to be seen, but one thing is certain: As technology, politics, society, medicine and the legal system continue evolving, so too will the DSM.

History of the DSM
The Diagnostic Statistical Manual originated in the 1840s when the U.S. Census made its first attempt to determine how many patients were confined to mental hospitals. At first, only a single category — idiocy/insanity — was used, but by 1880 the census listing had expanded to seven disorders including mania, melancholia, monomania, paresis, dementia, dipsomania and epilepsy.

In 1913, Dr. James May pleaded with the precursor to the APA, the American Medico Psychological Association, to create a uniform classification system. And though by 1917, the list had grown to 22, it wasn't until 1933 that the first edition of the Statistical Manual for Mental Diseases appeared. After several revisions the manual as it's known today, DSM-I, was published in 1952. (Three years earlier the World Health Organization's International Statistical Classification of Diseases included a section on mental diseases for the first time.)

That first DSM, which adopted much of its categorization system from the U.S. Army, listed 106 disorders.

In 1968, DSM-II was approved with 182 disorders and for the first time incorporated sociological and biological knowledge. A major controversy occurred following protests by gay activists from 1970 and 1973 over the inclusion of homosexuality as a disorder. It was dropped from the seventh edition of DSM-II in 1974, though ultimately replaced with "sexual orientation disturbance."

Also that year — under the leadership of Spitzer – DSM-III was created to make its nomenclature consistent with the ICD. More significantly, the DSM-III for the first time incorporated a research-based, empirical approach to diagnosis. When it was published in 1980, the text was now nearly 500 pages with 265 diagnostic categories.

The DSM-IV was completed in 1994, with a text revision in 2000. Its 297 categories embrace a "biologic" approach to diagnosis and are designed to improve communication between clinicians and researchers.