DSM-5: Terminology and Certainty. More Thoughts on Medical Naming: I
Just because your doctor has a name for your condition
doesn't mean he knows what it is.
Six Principles for Patients Murphy's Law, Book 2
They plotted a revolution, fell to debating among themselves, and in the end overturned very little except their own expectations.
Referring to debate among experts in the American Psychiatric Association preparing DSM-5
New York Times, Dec. 10, 2012
Does Everything Have a Name?
Human beings tend to invoke explanations for everything from existence itself to links between cause and effect. This is nothing more than an attempt to impose a narrative on the chaotic world we inhabit. Without that first step, giving names to everything, language, let alone communication, would be impossible. Yet, names and collections of them can sometimes be perilous if carried too far in a world suffused with the unnameable.
As Juliet remarked to Romeo, "What's in a name?" So it is with the problem of diagnosis in medicine, entangled inevitably with the problems of naming. As I have previously observed, in our attempt to translate our reality into words, we range from the idealized abstractions of mathematics and physics, .e.g. there are no synonyms for atom or neutron- to the fuzziness and ambiguities of medicine. This is reflected in the richness and complexities of our medical vocabulary. Consider how many words we have for cancer: malignancy, carcinoma, tumor, neoplasm, and related terms, as papilloma, adenoma, sarcoma, lymphoma, etc. But if words fail us in describing cancer, how often are they unsuitable as descriptions of human behavior reduced to diagnostic categories?
What is Mental Illness?
The most extreme views striking at the very existence of mental illness and thus the acceptance of psychiatric diagnosis, were expressed by Dr. Thomas Szasz, and others in 1960 who argued that mental illness was a myth or metaphor used to describe "offending, disturbing, shocking, conduct such as schizophrenia," and used to disguise the bitter pill of moral conflicts by creating "disease" out of patterns of behavior. Szasz wrote: "If you talk to God, you are praying; If God talks to you, you have schizophrenia. If the dead talk to you, you are a spiritualist; If you talk to the dead, you are a schizophrenic... While people behave and think in ways that are very disturbing, this does not mean they actually have a disease." To Szasz, disease can only mean something people "have while behavior is what people do.... No behavior or misbehavior is a disease or can be a disease. That's not what diseases are." Szasz, as well as Scheff and Goffman, believe that by calling certain people "diseased", psychiatry attempts to deny them responsibility as moral agents – in order to better control them.
Szasz's admittedly extreme position, though few agree, is certainly thought-provoking at the least. It might have implications that may or may not comfort bereaving families of victims in the unspeakable disaster in Newtown, Connecticut. But Szasz does imply, and our experience suggests, that it might be more effective to control guns than people. Here an entire community seeks answers for the unanswerable and inexplicable behavior of what some might label as a psychotic, depressed, evil, schizophrenic, even autistic person. (Asperger's has even been suggested.) If giving a name or names to the behavior of a 20 year old man who destroyed 26 lives and shattered the lives of countless others, offers us some comfort, then there can be no objection. Does this mean we must discard the simple notion of "craziness" as a failed attempt to explain the crime of gratuitous murder, let alone mass killing?
DSM and the APA
The American Psychiatric Association (APA) in its coming edition of "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5) is the latest in a long list of DSM's going back to 1952. The planned fifth edition of the diagnostic bible of mental disorders, is due for publication in May 2013. It will supersede the DSM-IV-TR last revised in 2000, which incidentally, sold nearly a million copies, and is now selling at Amazon for only $114.38 hard cover, $84.49 soft. Estimated income 10 years ago: $100 million.
DSM-5 has aroused old conflicts and controversies, perhaps less audacious than those of Szasz, but nonetheless revealing, by reminding us that human behavior in all its varieties has caused unanticipated problems of naming for psychiatry, if not medicine and society.
Glaring examples of pathologizing human behavior was made public by gay and straight activists who challenged the APA's listing of homosexuality as a mental disorder in the early 1970's. Another challenge that received embarrassing publicity was a classic study published in Science by David Rosenham On Being Sane in Unsane Places (1973) which was viewed as an attack on the meaning and practice of psychiatric diagnosis. The marketing of the DSM has been so effective that few people — even therapists — realize that psychiatrists rarely agree about how to label the same patient. "In a study by Philip Ash in which he had fifty-two mental patients examined by three psychiatrists, two of whom were internationally known, all reached the same diagnosis only 20% of the time, and two were in agreement less than 50% of the time". Quoted from the outstanding Health and Stress Newsletter, of my colleague, Dr. Paul J. Rosch, Mar. 2013.
Controversies and Impact
Whether the disorders DSM defines are actual conditions in people in the real world, is a question that, in a circular argument, is "consistently identified by its criteria." Critics, such as psychiatrist Niall McLaren argue that the DSM "lacks validity...(as well as) reliability partly because different diagnoses share many criteria... are often just rewordings of the same idea, meaning that the decision to allocate one diagnosis or another to a patient is to some extent a matter of personal prejudice." These long-standing criticisms are highlighted by the famous Rosenham experiment in the 1970s, using pseudopatients, imposters, and non-existent imposters.
Troubles in DSM World
The DSM classification of homosexuality as a mental disorder in the early 1970s, led to activists protesting at APA offices and at annual meetings for three years. In 1973 the Board of Trustees voted to remove homosexuality as a disorder category from the DSM. Hoping to satisfy the gay community, a category of "Sexual orientation disturbance" was introduced in its place in 1974, and then replaced in the 1980 DSM-III with "Ego dystonic sexual orientation," which was, in fact part of the original description. That was finally removed thirteen years later in 1987.
The final text of DSM-5, which won't be fully available until publication next month (May, 2013), has already received predictably mixed reviews. The New York Times reported patient advocacy groups "sounded off, objecting to proposed changes in the definitions of depression and Asperger Syndrome. Outside academic researchers also objected, while a few committee members quit in protest." Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke. has been one of the most vocal critics, of the fifth edition of DSM-5 wrote "This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry." See this important article by Dr. Frances.
For more proposed definitions of mental disorders, my next newsletter will address, among other "diseases," : Hoarding, binge eating, premenstrual dysphoria, grief, sadness, depression, autism, bipolar disorder, and other disorders associated with being human.
Martin F. Sturman, MD, FACP
Copyright 2012, Mathemedics, Inc.
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