7 ms·

Review of the DSM-V as a piece of dystopian fiction

148 points by carpdiem 13y ago

andrewcooke 13y ago
i don't understand this. if we assume psychiatry is pretty much in its infancy, blundering around, then doesn't it make sense to give names to certain groups of symptoms? because then you can hope to identify patterns. for example: if 60% of people who do X and feel Y take drug Z then P, Q and R. isn't that how you start doing science? i used to be more sympathetic to criticisms of DSM-V, but a couple of months back i went to see a psychiatrist. who told me he didn't believe in it. fair enough. but he then diagnosed me with something and prescribed me a drug. when i asked why, he said i should trust his intuition. without DSM-V or anything similar there was no structure - nothing i could understand or question. no logic. just "intuition". maybe i am missing the point. i can see that "labels" are annoying. but surely there has to be some systematic approach to symptoms... [edit: got psychiatry and psychology swapped...]
- kevingadd 13y ago
  I feel like the core criticism here isn't necessarily of structure itself, but that the type of structure applied when creating the DSM-V is not necessarily a helpful structure. Grouping things into neat categories and assigning them a name is useful in the case where structure actually helps patients, but it's possible to harm them just as much if it goes beyond being a diagnostic tool and rule of thumb. I don't think the DSM-V protects against the problem you observed when seeing a psych, either. I saw one a while back who did believe in the DSM-IV (V wasn't out at the time) and his approach was still 'it sounds like you fit the clinical definition of this; I can prescribe you this medication'. The diagnostic process was, ultimately, 'if this medication helps you probably have this condition'. I think it's reasonable for that to unnerve you, but that's really just a symptom of how difficult it is to actually draw concrete, verifiable conclusions about this stuff. Many of the conditions described in a tome like the DSM-V as a singular condition end up having wildly varied symptoms and there end up being treatments that only work for one subset of people with the condition, while another treatment only works for another subset. Some people who have a condition only show a tiny subset of the symptoms. I think it's reasonable to look at that and ask if some well-meaning people have gone overboard in an attempt to label and categorize everything. On a related note, there are many marginalized groups out there that feel victimized by the authors of tomes like the DSM, because it often classifies things as 'disorders' that ought not necessarily be a disorder. Those with unusual sexual orientations, gender identities, or social habits are among the people who at one time or another have been considered mentally deficient or mentally ill due to classification. I don't think the people authoring those classifications necessarily intended to harm those marginalized groups, but that often IS the result.
  - andrewcooke 13y ago
    i don't really disagree with you, but it seems to me that the problem is that there are good doctors and crappy doctors. DSM-V seems to be a side-issue; it's just a tool. arguing about it seems to be the psychiatric equivalent of criticising programming languages... (i got a second opinion from someone who spent much more time talking with me, understanding what was happening, and discussing possibilities. he used DSM-V as a framework that allowed him to structure things. that was all. he was awesome and i was happy with his decision. and that's because he was a good doctor, not because of DSM-V. but as a good doctor, he wasn't discarding a useful tool for "religious reasons") [edit: all the above is necessarily simplified; i now feel a bit guilty in portraying the first doctor so negatively. there's clearly factors like client-doctor "fit" involved, too.]
  - __float 13y ago
    The problem is that psychiatrists aren't really interested in much other than prescribing medications. Therapy is left to those with degrees in clinical psychology or social work. And from what I have experience with--the eating disorder community--many professionals actually discredit the DSM's categorization (though it has much improved in the DSM-5) because of its insistence on weight for diagnoses of anorexia nervosa. But great American insurance often will pay for nothing if the patient does not have either AN or BN leading to patients being "not sick enough" for treatment when really, they need it as soon as possible for recovery to be most successful.
    - Apocryphon 13y ago
      It also seems like there's a rivalry between psychiatrists and the psychologists. I wonder if the latter have their own equivalent text to the DSM.
- mjn 13y ago
  I read this piece as using the "what if the DSM was a novel" part mostly as a jumping-off point to satirize how we treat the idea of happiness and normality, rather than being explicitly a criticism of the manual itself as a diagnostic tool. A "weak interpretation" of the DSM where it's a collection of clustered symptoms, together with some advice about what treatments appear to have worked or not worked in the past for them, wouldn't really run into that. But some people do seem to have a stronger interpretation where the manual acquires a normative/definitional component, in which it's supposed to define the line between "mentally ill" and "normal psyche". Then you get into a huge amount of uncertainty that we still have over the etiology of any of these conditions, plus political battles over what counts as normal in the first place, the long fight over whether homosexuality should be included being probably the most famous example. Occasionally legal status can even be tied to being diagnosed as "mentally ill", which is where it starts coming closest to the dystopian-novel feel, although that may be the fault of legislators more than psychiatrists. I guess the part of this article that's most explicitly a critique is this: > DSM-5 seems to have no definition of happiness other than the absence of suffering. ...but that only really applies to certain ways of using the DSM, the weak pragmatic one not being among them, since it would recognize that treating acute suffering is only a small component of human psychology in the more general sense.
- DanBC 13y ago
  > but he then diagnosed me with something and prescribed me a drug. when i asked why, he said i should trust his intuition DSM or no, too many doctors prescribe medication off-label. People with one of the personality disorders get a diagnosis and then some semi-random medication with some experimental[1] psychotherapy. All the clinicians disagree about what the treatment should be, but they see that as a feature of the patient's illness. Thus, if the patient is doing exactly what Dr A wants (but not what Dr B wants) Dr B will say it's the patient's manipulation which is part of the illness, and not that it's just a conflict among the team I'm not sure how it works in the US, but some psychiatric diagnoses can be used to detain a person in hospital against their will. There's no court process, no judge. There are some protections, but these are not great.
  - mjn 13y ago
    On the latter part, this is pretty rare now in the US. Involuntary "holds" are almost always short-term, and only initiated when there's some disturbance that results in the police being called. In California, for example, a 72-hour hold is the most common, although 2-week and longer holds are possible: http://en.wikipedia.org/wiki/5150_(involuntary_psychiatric_hold) http://en.wikipedia.org/wiki/5150_(involuntary_psychiatric_h... The downside is that the old system of involuntary commitment, which I do believe civil-liberties campaigners were right to campaign against, has not really been replaced with anything. Some proportion of those who were previously involuntarily committed are better off, living some kind of life, whether a normal one, or some kind of bohemian one, or with family, or otherwise getting by. But some proportion are a mixture of homeless and in and out of jail or 72-hour holds, without any serious long-term attempt to do anything about their situation. Especially true if either they lack close family, or lack family with enough means to take them in, or have psychotic episodes that their family finds threatening. A schizophrenic guy I know through the tech scene is in that category; has been 72-hour held 4 or 5 times, on a 2-week hold once, arrested for various kinds of minor disturbances a dozen times, etc., but never received much treatment, except during the short periods of psychiatric confinement.
  - cloverich 13y ago
    Varies from state to state, http://en.wikipedia.org/wiki/Involuntary_commitment#United_States http://en.wikipedia.org/wiki/Involuntary_commitment#United_S... I did a 6-week rotation in a psych ward for exclusively psychotic patients ( mostly schizophrenic, some manic). I can't recall if they were all held specifically for being a danger to themselves / others, but remember court orders being regularly obtained (and always required) and then only for patients who were very psychotic (medically psychotic --> delusional, typically to the point of being unable to function).
- Alex3917 13y ago
  > i used to be more sympathetic to criticisms of DSM-V, but a couple of months back i went to see a psychiatrist. who told me he didn't believe in it. fair enough. but he then diagnosed me with something and prescribed me a drug. when i asked why, he said i should trust his intuition. without DSM-V or anything similar there was no structure - nothing i could understand or question. no logic. just "intuition". You do realize that one of the biggest criticisms of the DSM-5 is that the inter-rater reliability for many diagnoses is no better than a coin flip, right?
  - andrewcooke 13y ago
    then fix those, but don't throw the baby out with the bathwater. the problem is that, at least in my case, DSM-V was replaced with an appeal to authority. when the alternative is "ok boss, you know best" i prefer a list of symptoms where i can argue, "look, almost anyone could tick half these boxes at some point in their lives". at least i can see what's happening. i am not saying that DSM-V is a rule book that should be followed blindly. i am not saying that it is "right", or that it carries some kind of moral weight. all that i am saying is that any communication - even dissent - needs a common vocabulary, and DSM-V can provide that. from my outside perspective it seems that it's a tool; that the real problem is some of the doctors. discarding the tool won't improve the bad doctors, it will just make them less accountable. how is that an improvement?
    - harvestmoon 13y ago
      You seem to not realize that the DSM-5 can be used to justify treating you with a wide variety of medications. If you feel a little down, occasionally feel a bit energized and happy, and sometimes anxious, using the DSM 5 your shrink can gladly give you: antidepressants antipsychotics anxiety medications and more.
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      - andrewcooke 13y ago
- davidp 13y ago
  The problem is that the DSM has become the de facto authority on what exactly constitutes an illness -- i.e is coverable by insurance. If your problem isn't in the DSM, insurers can in many cases safely deny coverage. So now we have the situation where an unelected, private body (the American Psychiatric Association) wields immense power over people's daily lives. This is the problem the author is alluding to in this passage: > On some level we’re to imagine that the American Psychiatric Association is a body with real powers, that the “Diagnostic and Statistical Manual” is something that might actually be used, and that its caricature of our inner lives could have serious consequences. Sections like those on the personality disorders offer a terrifying glimpse of a futuristic system of repression, one in which deviance isn’t furiously stamped out like it is in Orwell’s unsubtle Oceania, but pathologized instead.
- jerf 13y ago
  My abnormal psych professor made a big deal of the fact that the DSM names things first and foremost so they can be talked about. So that when one psychologist says to another "This patient exhibits blahdebleh with specific hemahummahoo", they have reasonable expectations that they are at least talking about the same symptoms. Perhaps they are talking about the same underlying cause, perhaps not, but at least they'll be talking about what appears on the surface to be the same thing, which is better than nothing. Psychologists are well aware that, for instance, "schizophrenia" (and I'm not going to check whether that's still in the DSM V, if not the point here holds) is probably more than one thing, and as soon as they work out the details, they will be given multiple names. In the meantime, so that everyone is on the same page, it has a description as clear as possible (which is not always very clear). The DSM is intended to be descriptive, not prescriptive, and not exhaustive. It is also not intended to be casually perused by people who don't understand the purpose, because of the high probability of suffering Medical Student's Disease [1] as a result. [1]: http://en.wikipedia.org/wiki/Medical_students%27_disease http://en.wikipedia.org/wiki/Medical_students%27_disease
  - thirdtruck 13y ago
    Kind of like how "a headache" is a grossly simplistic term, given how many varieties and underlying causes we know of today, but we still need that anchor point long before discussing the prescription of aspirin vs. tumor surgery.
- foolrush 13y ago
  It might help to borrow a smidge from Foucault's History of Madness. What impact does labelling have beyond a purely descriptive belief? Is there an ideological conflict between what is mad and what is not? The simplest example that comes to mind is hysteria. We can easily see how this well discussed ‘ailment’ was actually an undercurrent of misogyny and class warfare. This goes hand in hand with the various forms of dysfunctional medicalization over the years. From Lombroso to the medicalization of the woman, the African American, the Jewish Race, etc. There appears much more at stake than benevolent labelling.
- LekkoscPiwa 13y ago
  you need to understand that DSM-V is the same intuition voted into existence by many doctors instead of one. The same BS at the end of the day. Who in their right mind would call a science a subject where we vote/unvote things into existence or deny their existence by voting process? Can you imagine the best in the world physicists voting in the beginning of 20th Century if Einstein theory of relativity is true or not? 90% of the vote would be that Einstein is wrong. However, nature and real science don't give a shit about democratic process. It's all about facts. And the facts, especially in pseudo-science like psychiatry - could be very, very damaging to the status quo.
  - icebraining 13y ago
    But is it really different than when the IAU decided our solar system has now planet less? The DSM isn't - from what I can tell - deciding that observable phenomena doesn't exist, but changing its classification, and that's something not derivable from facts.
    - VLM 13y ago
      Another good example, 620 nm, is that red or orange light?
      - LekkoscPiwa 13y ago
        For me it's more of is Sun going around the Earth, or the Earth around the Sun types of questions. Something very basic. I.e. is there a sex addiction or not? Is homosexuality a "disease" or not? I mean you do have whole movements like anti-psychiatry movement that basically are in total opposition to everything that psychiatry claims. I can go to a psychiatrist and persuade him/her that I have a bipolar disorder. Or that I'm schizophrenic, or depressive. And that's because there is no way for psychiatrists to know. You can talk all day long about all types of brain imaging tests that could reveal the diseases. But if that in fact was true then psychiatry would use the tools in the diagnostic process. If nothing else then at least to shut up guys like me who laugh at that "science". Do you think that I can't go to 3 doctors and persuade each of them that I have a psychiatric condition and that they wouldn't give me a diagnosis?
__float 13y ago
If anyone wants to Google more about the book, it might help to know the actual book is the "DSM-5". They have discontinued the Roman numeral scheme in the latest edition (released this year), but some still use the old way.
- deleted 13y ago
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DanBC 13y ago
> This is one of the major flaws in George Orwells’s 1984: When O’Brien laughingly expounds on his vision of “a boot stamping on a human face – forever” Sounds about right. (http://imgur.com/a/IJnR2 http://imgur.com/a/IJnR2)
bhaumik 13y ago
If anyone's curious about the changes in DSM-5 (from DSM-IV) here are the "highlights": http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20t... Very interesting additions/clarifications.
chimeracoder 13y ago
> “caffeine intoxication disorder.” As someone who mostly appreciated the DSM-IV (though recognized its shortcomings), this is my biggest concern with the DSM-V, and why I consider it to be a step backwards in many ways. CAVEAT: My understanding of the DSM-V is based on earlier drafts/non-final editions, so some of these details may be stale, but it appears the general principles that I object to haven't changed. The DSM-IV-TR was very specific with its definitions of "substance abuse" and "substance dependence". My main complaint with the former was the way two of the criteria were poorly worded. It referred to the amount of legal trouble and/or risk that the person took to obtain the drug and could, if very broadly (mis-)interpreted, be used to identify any user of any illegal drug as suffering from "substance abuse" just by definition[0]. This is mostly a quibble about the wording of one detail, though; I think that these were good definitions overall and were more helpful than not. Criticially, the DSM-IV-TR was able to distinguish between casual users of a drug (be it caffeine, alcohol, marijuana, heroin, etc.) and those who actually suffered from "addition" (a term I put in scare quotes because it does not have a medical definition, unlike the words "abuse" and "dependence"). This is a crucial distinction. If you send someone who drinks infrequently but is not an alcoholic to rehab, you are providing treatment for a disorder that they do not have. Thus, you wouldn't be surprised (or concerned) to find their behavior unchanged six months later. You would not consider it a "relapse" if they continued to drink infrequently. Unfortunately, the DSM-V turns this on its head, by allowing "fill-in-the-blank" intoxication disorders. Think of generic classes in Java - they work the same way. Given the name of any drug, you can provide the corresponding disorder - in this case, "caffeine intoxication disorder", or "marijuana abuse syndrome"[1] The problem with the new wording is that it encourages over-diagnosis of mental disorders. Instead of requiring a professional to distinguish between disorders and non-disorders (easy), it lumps all together as disorders, and requires professionals to distinguish between those which require treatment and those which don't (hard). This is not only more difficult medically, but more problematic legally. No doctor or hospital wants to accept the liability of saying that they saw a patient previously diagnosed with a disorder and then determined that they didn't need treatment. This is far worse than simply failing to diagnose a disorder. This may seem like a minor point, but it's not. We've been struggling with issues of overdiagnosis and overtreatment of non-disorders (not just drug-related) for years; in a very subtle way, the DSM-V further entrenches this problem. [0] Incidentally, DSM-V did drop the "legal trouble" criterion. [1] I forget the exact wording of the latter; this was a while ago and I believe they changed it.
ACow_Adonis 13y ago
One is reminded of other fictional works such as American Psycho, by Brett Easton Ellis. These works are valuable to read not because they are overly pleasant, but specifically because they are such transparent and horrific reflections of the inner mental state of the narrator. Such a state is then projected onto the mind of the reader so effectively that the disgust and alienation you feel while reading the book is effectively the same disgust and alienation internalised at all times by the novel's protagonist. In this the DSM-V is another brilliant piece of fictional writing. A world where everything is classified, pathologised, and detached from its context, values, society, and causes. During the entire tome, you are completely separated from any notion of wellness, love, morality, or healthy human beings, with everything classified and filed away like a work-bench with little boxes for every possible failing. It finally hits you as you feel so disgusted and alienated by the conclusion of the novel...that this is specifically because the narrator is so alienated and separated from such realities, and the novel has succeeded perfectly in its goal. To put you in such a tortured, flawed, and erroneous mindset that you now understand completely the flawed and erroneous mindset and worldview of the narrator. Kudos to the author. Another masterpiece.
yuubi 13y ago
"system of repression . . . in which deviance isn’t furiously stamped out . . . but pathologized instead." For instance, https://en.wikipedia.org/wiki/Sluggishly_progressing_schizophrenia https://en.wikipedia.org/wiki/Sluggishly_progressing_schizop...
chaffneue 13y ago
This article is just purple prose nonsense that takes advantage of their audience's natural distrust of information that surrounds the human mind (see the author's reference to multiple benign conditions to discredit the work) and the author's own hang up about some sad end where "human beings are individuated, sick, and alone." From pioneers like Freud to the modern psychoanalysis spectra we have today, I see much of the body of work around human mental states being about classification/categorization, statistical aggregation, symptom/diagnosis tracking and vocabulary. The article is more or less reading a collection of codified medical anomalies and then attributing a singular, malevolent narrative tone to it instead of just reading it for what it is: a standardized professional manual with a strict written style and many collaborators. There's no narration let alone an "unreliable" narrator, there's minimal subjectivity, there are no actors, there's just some observational information presented in a standard way. While I'm aware the DSM has its critics and naff list of non-disorders, I don't believe that committing to basic research and presenting objective findings is a madness that itself belongs in the DSM. What if the goal to this manual is altruistic? What if even one patient benefits from a faster recovery from some mental malaise because of this manual? I'm inclined to say keep researching!
- mjn 13y ago
  > What if the goal to this manual is altruistic? That doesn't sound at all out of line with a typical dystopian novel plot. :)
  - chaffneue 13y ago
    Haha! good point!
- deleted 13y ago
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chattoraj 13y ago
The NIMH (National Institute of Mental Health) announced a few months ago that it would be "re-orienting its research away from DSM categories". Even the guys on the inside don't trust it. http://mindhacks.com/2013/05/03/national-institute-of-mental-health-abandoning-the-dsm/ http://mindhacks.com/2013/05/03/national-institute-of-mental...
davidjohnstone 13y ago
One of the criticisms being leveled at the DSM-V here is that "normal" is being negatively defined as the absence of disorder: > DSM-5 seems to have no definition of happiness other than the absence of suffering. The normal individual in this book is tranquilized and bovine-eyed, mutely accepting everything in a sometimes painful world without ever feeling much in the way of anything about it. Positive psychology[1] is a branch of psychology that agrees with this critique, and rather than looking at what goes wrong with people, it looks at what is right about people. There is a book "Character Strengths and Virtues"[2] that is aimed at being the positive counterpart to the DSM, providing a taxonomy of character strengths that have been identified across different times and cultures. 1. http://en.wikipedia.org/wiki/Positive_psychology http://en.wikipedia.org/wiki/Positive_psychology 2. http://en.wikipedia.org/wiki/Character_Strengths_and_Virtues http://en.wikipedia.org/wiki/Character_Strengths_and_Virtues
- einhverfr 13y ago
  Not only is normal defined as the absence of disorder, but disorders are viewed dimensionally rather than categorically, so to some extent they apply to everybody.
  - _delirium 13y ago
    For many disorders, the extent to which they apply on an axis is also, when it comes down to it, defined relative to whether it causes trouble for one's job or not. This is written explicitly into many of the diagnostic criteria, so that the same objective behaviors would be a disorder for a person with one job, where they pose a serious problem to their ability to carry on that occupation, but not for another person with another job, where the behavior is no threat to their livelihood. But this begs the question [1] of whether it's the person or the job that's "at fault" or "abnormal". That's where some of the criticism originates: one allegation is that perfectly normal people are being diagnosed as mentally ill and told they need treatment, when they are maladapted to a job that in fact most humans are maladapted to. In other words, they are within the normal range of human behavior, but treated as mentally ill because their job expects abnormal human behavior. [1] In the precise meaning of the term.
tokenadult 13y ago
I see chimeracoder has already posted a comment here. Maybe I should plunge in, after looking at the "book review" kindly posted here, to comment on psychiatric nosology (classification of disorders) in general. Basis of knowledge disclaimer: I am not a medical doctor, and I have never attended even an undergraduate-level course in psychology. On the other hand, I have been reading extensively about psychology for twenty years,[1] mostly focusing on research on human intelligence and human behavior genetics, and over the years my participation in online discussion networks gained me an invitation to participate in the "journal club" (graduate seminar course) on human behavior genetics at my alma mater. At the behavior genetics seminar, I have met several researchers who have been trying to clean up psychiatric nosology and improve the newly released edition of DSM. The researchers I know locally do NOT like the framework or approach of DSM-5. I'll try to do a layman's justice to their point of view in what I write below. We have discussed before here on HN the blog of the director of the National Institutes of Mental Health, which included a post "Transforming Diagnosis,"[2] casting considerable doubt on the diagnostic approach taken in DSM-5, which was published just before DSM-5 itself was published. Most researchers agree that to develop better understanding of troubles patients experience, and better approaches to treatment, a lot of mental disorders will have to be recategorized (including no longer being categorized as disorders) based on new criteria. That's what the progress of science will look like in this field. It's important to remember that Freudianism was still in vogue when I was young (and constituted most of the higher education in psychology that my parents received in the early 1950s) and psychology and especially psychiatry are STILL undoing some of the harm caused to those disciplines by mistaken ideas from Sigmund Freud. It's easy to tell persuasive stories about what makes people's minds work, but much harder to test those stories with evidence. Neurologists who are interested in science-based improvement of medical practice have commented[3] on DSM-5, and comments of that kind point the way forward to improvement of nosology in psychiatry in the future. Therapists may have to give up their pet "specialities" to recognize the realities of how to help patients. There will surely still have to be new diagnostic tests and new drug treatments developed. The DSM-5 didn't do as well as it ought to have to advance understanding of mental disorders. But its evident faults will prompt further research, and DSM-5 will eventually be replaced by a new edition, one I hope will be based on better science. [1] https://en.wikipedia.org/wiki/User:WeijiBaikeBianji/IntelligenceCitations https://en.wikipedia.org/wiki/User:WeijiBaikeBianji/Intellig... [2] http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml http://www.nimh.nih.gov/about/director/2013/transforming-dia... [3] http://www.sciencebasedmedicine.org/dsm-5-and-the-fight-for-the-heart-of-psychiatry/ http://www.sciencebasedmedicine.org/dsm-5-and-the-fight-for-...
wavesounds 13y ago
"The word “disorder” occurs so many times that it almost detaches itself from any real signification, so that the implied existence of an ordered state against which a disorder can be measured nearly vanishes is almost forgotten. .... Here all pretensions to objectivity fall apart and the novel’s carefully warped imitation of scientific categories fades into an examination of petty viciousness." Or as Richard Feynman coined it: Cargo Cult Science http://en.wikipedia.org/wiki/Cargo_cult_science http://en.wikipedia.org/wiki/Cargo_cult_science Also lets not forget these same people claimed being homosexual was a mental disorder until 1973!
jboynyc 13y ago
Ian Hacking had a great review of the DSM-5 in the LRB earlier this year: http://www.lrb.co.uk/v35/n15/ian-hacking/lost-in-the-forest http://www.lrb.co.uk/v35/n15/ian-hacking/lost-in-the-forest
thucydides 13y ago
Great piece. Two of my favorite substantive critiques: 1. "DSM-5 seems to have no definition of happiness other than the absence of suffering. The normal individual in this book is tranquilized and bovine-eyed..." The DSM does turn mental disease into an entirely negative subject: you're mentally healthy only if you lack any of the listed disorders. The name "Diagnostic and Statistical Manual" does limit the enterprise contained within, but practically speaking, the DSM is the Bible for mental health professionals. It's the document that describes a substantial portion of how to give care to the mentally sick, and no other document has the same stature. And yet their Bible contains nothing at all about mental hygiene or positive practices. Consider how odd that is, how it distorts the mental health professions. In the realm of "physical" health, medical doctors speak with unanimity on every medium imaginable about how you should exercise regularly, eat more fruits and vegetables, etc., to stave off cancer, diabetes, heart disease, and an array of other ailments. How often do you hear psychiatrists talk about the importance of working on your empathy and forgiveness skills? N.B.: doing so will make you happier. Again, cataloguing symptoms is important, but not all-important. DSM sucks all the air out of the room and leads those who study the mind to focus excessively on the neat categorization of symptoms rather than means of staving off mental illness in the first place or of developing admirable virtues like courage, self-discipline, and justice. 2. "On some level we’re to imagine that the American Psychiatric Association is a body with real powers, that the Diagnostic and Statistical Manual is something that might actually be used, and that its caricature of our inner lives could have serious consequences." We know that the caricatures have serious consequences for millions of people, which ought to horrify us. I've seen the consequences of this kind of over-pathologization up close. I've had several criminal clients who've been seriously affected by faulty prison diagnoses of schizophrenia and bipolar disorder. These faulty diagnoses led to the prescription of the powerfully soporific antipsychotic Risperdal, which turned my clients into physically weak zombies, and, for that reason, into victims of sexual assault. Admittedly this is an extreme example, but it amply demonstrates the power of the DSM.
- Dylan16807 13y ago
  I understand misdiagnosis of many things, but how do you get misdiagnosed as schizophrenic?
morgante 13y ago
I feel pretty stupid for taking so long to realize that this is an actual review of the DSM-5. Up until halfway through, I thought this was indeed a review of brilliantly executed satire in the form of the DSM. Though that itself could actually be a pretty interesting literary form...
fit2rule 13y ago
The thing about the DSM-V is that it is simultaneously a bible, a dictionary, a sales catalog, and an industrial reference manual. As a work of literature, it is the pinnacle of mans' oppression of mankind, categorized, classified. Any single manner by which one might criticize ones fellows, put them in a box, and prepare for delivery: DSM-V has it.
Sagat 13y ago
I have trouble taking psychology and psychiatry seriously. They are the softest of the sciences and mostly based on cultural norms anyway. Consider the fact that homosexuality was labelled a mental disorder in the DSM not long ago. This is evidence that they make it up as they go along.
- DanBC 13y ago
  > Consider the fact that homosexuality was labelled a mental disorder in the DSM not long ago. It was removed in about 1975. There's plenty of dumb stuff done in many areas of science 40 years ago.
philwelch 13y ago
What I think a lot of people are missing is that the entire notion of mental illness is a hack. The basic definition of any mental illness requires that it interferes with ones ability to live a normal life. Resist the urge to deconstruct that for a second, I'll come back to it. Some people have problems that some type of professional help can enable them to solve. This can range from people who need medication to avoid seeing and hearing things that aren't there to people who need CBT to get out of a self-destructive rut to people who need cosmetic surgery to feel like their body fits their subjective gender. But the United States is full of systems where you need a diagnosis to do anything--bill insurance, prescribe medication, declare someone to have a disability so they can collect income without working. So DSM is a tool for psychologists and psychiatrists to put a code down on a form so the system will let them help people. This is why there's a stipulation that it's only a mental illness if it prevents you from living a normal life. Lots of people have the symptoms of mental illness, just not to such a degree that it warrants intervention. Having compulsive rituals is perfectly normal--compulsively washing your hands until they bleed is not. A good mental health professional will know the difference and only provide a diagnosis when it's necessary. But ultimately the DSM isn't a bedrock of abnormal psychology, it's just a tool psychologists use to make the system let them help people.
- 001sky 13y ago
  The entire notion of mental illness is a hack-Job. That sounds about right.

148 points by carpdiem 13y ago

i don't understand this. if we assume psychiatry is pretty much in its infancy, blundering around, then doesn't it make sense to give names to certain groups of symptoms? because then you can hope to identify patterns. for example: if 60% of people who do X and feel Y take drug Z then P, Q and R. isn't that how you start doing science? i used to be more sympathetic to criticisms of DSM-V, but a couple of months back i went to see a psychiatrist. who told me he didn't believe in it. fair enough. but he then diagnosed me with something and prescribed me a drug. when i asked why, he said i should trust his intuition. without DSM-V or anything similar there was no structure - nothing i could understand or question. no logic. just "intuition". maybe i am missing the point. i can see that "labels" are annoying. but surely there has to be some systematic approach to symptoms... [edit: got psychiatry and psychology swapped...]

kevingadd 13y ago
I feel like the core criticism here isn't necessarily of structure itself, but that the type of structure applied when creating the DSM-V is not necessarily a helpful structure. Grouping things into neat categories and assigning them a name is useful in the case where structure actually helps patients, but it's possible to harm them just as much if it goes beyond being a diagnostic tool and rule of thumb. I don't think the DSM-V protects against the problem you observed when seeing a psych, either. I saw one a while back who did believe in the DSM-IV (V wasn't out at the time) and his approach was still 'it sounds like you fit the clinical definition of this; I can prescribe you this medication'. The diagnostic process was, ultimately, 'if this medication helps you probably have this condition'. I think it's reasonable for that to unnerve you, but that's really just a symptom of how difficult it is to actually draw concrete, verifiable conclusions about this stuff. Many of the conditions described in a tome like the DSM-V as a singular condition end up having wildly varied symptoms and there end up being treatments that only work for one subset of people with the condition, while another treatment only works for another subset. Some people who have a condition only show a tiny subset of the symptoms. I think it's reasonable to look at that and ask if some well-meaning people have gone overboard in an attempt to label and categorize everything. On a related note, there are many marginalized groups out there that feel victimized by the authors of tomes like the DSM, because it often classifies things as 'disorders' that ought not necessarily be a disorder. Those with unusual sexual orientations, gender identities, or social habits are among the people who at one time or another have been considered mentally deficient or mentally ill due to classification. I don't think the people authoring those classifications necessarily intended to harm those marginalized groups, but that often IS the result.
- andrewcooke 13y ago
  i don't really disagree with you, but it seems to me that the problem is that there are good doctors and crappy doctors. DSM-V seems to be a side-issue; it's just a tool. arguing about it seems to be the psychiatric equivalent of criticising programming languages... (i got a second opinion from someone who spent much more time talking with me, understanding what was happening, and discussing possibilities. he used DSM-V as a framework that allowed him to structure things. that was all. he was awesome and i was happy with his decision. and that's because he was a good doctor, not because of DSM-V. but as a good doctor, he wasn't discarding a useful tool for "religious reasons") [edit: all the above is necessarily simplified; i now feel a bit guilty in portraying the first doctor so negatively. there's clearly factors like client-doctor "fit" involved, too.]
- __float 13y ago
  The problem is that psychiatrists aren't really interested in much other than prescribing medications. Therapy is left to those with degrees in clinical psychology or social work. And from what I have experience with--the eating disorder community--many professionals actually discredit the DSM's categorization (though it has much improved in the DSM-5) because of its insistence on weight for diagnoses of anorexia nervosa. But great American insurance often will pay for nothing if the patient does not have either AN or BN leading to patients being "not sick enough" for treatment when really, they need it as soon as possible for recovery to be most successful.
  - Apocryphon 13y ago
    It also seems like there's a rivalry between psychiatrists and the psychologists. I wonder if the latter have their own equivalent text to the DSM.
mjn 13y ago
I read this piece as using the "what if the DSM was a novel" part mostly as a jumping-off point to satirize how we treat the idea of happiness and normality, rather than being explicitly a criticism of the manual itself as a diagnostic tool. A "weak interpretation" of the DSM where it's a collection of clustered symptoms, together with some advice about what treatments appear to have worked or not worked in the past for them, wouldn't really run into that. But some people do seem to have a stronger interpretation where the manual acquires a normative/definitional component, in which it's supposed to define the line between "mentally ill" and "normal psyche". Then you get into a huge amount of uncertainty that we still have over the etiology of any of these conditions, plus political battles over what counts as normal in the first place, the long fight over whether homosexuality should be included being probably the most famous example. Occasionally legal status can even be tied to being diagnosed as "mentally ill", which is where it starts coming closest to the dystopian-novel feel, although that may be the fault of legislators more than psychiatrists. I guess the part of this article that's most explicitly a critique is this: > DSM-5 seems to have no definition of happiness other than the absence of suffering. ...but that only really applies to certain ways of using the DSM, the weak pragmatic one not being among them, since it would recognize that treating acute suffering is only a small component of human psychology in the more general sense.
DanBC 13y ago
> but he then diagnosed me with something and prescribed me a drug. when i asked why, he said i should trust his intuition DSM or no, too many doctors prescribe medication off-label. People with one of the personality disorders get a diagnosis and then some semi-random medication with some experimental[1] psychotherapy. All the clinicians disagree about what the treatment should be, but they see that as a feature of the patient's illness. Thus, if the patient is doing exactly what Dr A wants (but not what Dr B wants) Dr B will say it's the patient's manipulation which is part of the illness, and not that it's just a conflict among the team I'm not sure how it works in the US, but some psychiatric diagnoses can be used to detain a person in hospital against their will. There's no court process, no judge. There are some protections, but these are not great.
- mjn 13y ago
  On the latter part, this is pretty rare now in the US. Involuntary "holds" are almost always short-term, and only initiated when there's some disturbance that results in the police being called. In California, for example, a 72-hour hold is the most common, although 2-week and longer holds are possible: http://en.wikipedia.org/wiki/5150_(involuntary_psychiatric_hold) http://en.wikipedia.org/wiki/5150_(involuntary_psychiatric_h... The downside is that the old system of involuntary commitment, which I do believe civil-liberties campaigners were right to campaign against, has not really been replaced with anything. Some proportion of those who were previously involuntarily committed are better off, living some kind of life, whether a normal one, or some kind of bohemian one, or with family, or otherwise getting by. But some proportion are a mixture of homeless and in and out of jail or 72-hour holds, without any serious long-term attempt to do anything about their situation. Especially true if either they lack close family, or lack family with enough means to take them in, or have psychotic episodes that their family finds threatening. A schizophrenic guy I know through the tech scene is in that category; has been 72-hour held 4 or 5 times, on a 2-week hold once, arrested for various kinds of minor disturbances a dozen times, etc., but never received much treatment, except during the short periods of psychiatric confinement.
- cloverich 13y ago
  Varies from state to state, http://en.wikipedia.org/wiki/Involuntary_commitment#United_States http://en.wikipedia.org/wiki/Involuntary_commitment#United_S... I did a 6-week rotation in a psych ward for exclusively psychotic patients ( mostly schizophrenic, some manic). I can't recall if they were all held specifically for being a danger to themselves / others, but remember court orders being regularly obtained (and always required) and then only for patients who were very psychotic (medically psychotic --> delusional, typically to the point of being unable to function).
Alex3917 13y ago
> i used to be more sympathetic to criticisms of DSM-V, but a couple of months back i went to see a psychiatrist. who told me he didn't believe in it. fair enough. but he then diagnosed me with something and prescribed me a drug. when i asked why, he said i should trust his intuition. without DSM-V or anything similar there was no structure - nothing i could understand or question. no logic. just "intuition". You do realize that one of the biggest criticisms of the DSM-5 is that the inter-rater reliability for many diagnoses is no better than a coin flip, right?
- andrewcooke 13y ago
  then fix those, but don't throw the baby out with the bathwater. the problem is that, at least in my case, DSM-V was replaced with an appeal to authority. when the alternative is "ok boss, you know best" i prefer a list of symptoms where i can argue, "look, almost anyone could tick half these boxes at some point in their lives". at least i can see what's happening. i am not saying that DSM-V is a rule book that should be followed blindly. i am not saying that it is "right", or that it carries some kind of moral weight. all that i am saying is that any communication - even dissent - needs a common vocabulary, and DSM-V can provide that. from my outside perspective it seems that it's a tool; that the real problem is some of the doctors. discarding the tool won't improve the bad doctors, it will just make them less accountable. how is that an improvement?
  - harvestmoon 13y ago
    You seem to not realize that the DSM-5 can be used to justify treating you with a wide variety of medications. If you feel a little down, occasionally feel a bit energized and happy, and sometimes anxious, using the DSM 5 your shrink can gladly give you: antidepressants antipsychotics anxiety medications and more.
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davidp 13y ago
The problem is that the DSM has become the de facto authority on what exactly constitutes an illness -- i.e is coverable by insurance. If your problem isn't in the DSM, insurers can in many cases safely deny coverage. So now we have the situation where an unelected, private body (the American Psychiatric Association) wields immense power over people's daily lives. This is the problem the author is alluding to in this passage: > On some level we’re to imagine that the American Psychiatric Association is a body with real powers, that the “Diagnostic and Statistical Manual” is something that might actually be used, and that its caricature of our inner lives could have serious consequences. Sections like those on the personality disorders offer a terrifying glimpse of a futuristic system of repression, one in which deviance isn’t furiously stamped out like it is in Orwell’s unsubtle Oceania, but pathologized instead.
jerf 13y ago
My abnormal psych professor made a big deal of the fact that the DSM names things first and foremost so they can be talked about. So that when one psychologist says to another "This patient exhibits blahdebleh with specific hemahummahoo", they have reasonable expectations that they are at least talking about the same symptoms. Perhaps they are talking about the same underlying cause, perhaps not, but at least they'll be talking about what appears on the surface to be the same thing, which is better than nothing. Psychologists are well aware that, for instance, "schizophrenia" (and I'm not going to check whether that's still in the DSM V, if not the point here holds) is probably more than one thing, and as soon as they work out the details, they will be given multiple names. In the meantime, so that everyone is on the same page, it has a description as clear as possible (which is not always very clear). The DSM is intended to be descriptive, not prescriptive, and not exhaustive. It is also not intended to be casually perused by people who don't understand the purpose, because of the high probability of suffering Medical Student's Disease [1] as a result. [1]: http://en.wikipedia.org/wiki/Medical_students%27_disease http://en.wikipedia.org/wiki/Medical_students%27_disease
- thirdtruck 13y ago
  Kind of like how "a headache" is a grossly simplistic term, given how many varieties and underlying causes we know of today, but we still need that anchor point long before discussing the prescription of aspirin vs. tumor surgery.
foolrush 13y ago
It might help to borrow a smidge from Foucault's History of Madness. What impact does labelling have beyond a purely descriptive belief? Is there an ideological conflict between what is mad and what is not? The simplest example that comes to mind is hysteria. We can easily see how this well discussed ‘ailment’ was actually an undercurrent of misogyny and class warfare. This goes hand in hand with the various forms of dysfunctional medicalization over the years. From Lombroso to the medicalization of the woman, the African American, the Jewish Race, etc. There appears much more at stake than benevolent labelling.
LekkoscPiwa 13y ago
you need to understand that DSM-V is the same intuition voted into existence by many doctors instead of one. The same BS at the end of the day. Who in their right mind would call a science a subject where we vote/unvote things into existence or deny their existence by voting process? Can you imagine the best in the world physicists voting in the beginning of 20th Century if Einstein theory of relativity is true or not? 90% of the vote would be that Einstein is wrong. However, nature and real science don't give a shit about democratic process. It's all about facts. And the facts, especially in pseudo-science like psychiatry - could be very, very damaging to the status quo.
- icebraining 13y ago
  But is it really different than when the IAU decided our solar system has now planet less? The DSM isn't - from what I can tell - deciding that observable phenomena doesn't exist, but changing its classification, and that's something not derivable from facts.
  - VLM 13y ago
    Another good example, 620 nm, is that red or orange light?
    - LekkoscPiwa 13y ago
      For me it's more of is Sun going around the Earth, or the Earth around the Sun types of questions. Something very basic. I.e. is there a sex addiction or not? Is homosexuality a "disease" or not? I mean you do have whole movements like anti-psychiatry movement that basically are in total opposition to everything that psychiatry claims. I can go to a psychiatrist and persuade him/her that I have a bipolar disorder. Or that I'm schizophrenic, or depressive. And that's because there is no way for psychiatrists to know. You can talk all day long about all types of brain imaging tests that could reveal the diseases. But if that in fact was true then psychiatry would use the tools in the diagnostic process. If nothing else then at least to shut up guys like me who laugh at that "science". Do you think that I can't go to 3 doctors and persuade each of them that I have a psychiatric condition and that they wouldn't give me a diagnosis?

__float 13y ago

If anyone wants to Google more about the book, it might help to know the actual book is the "DSM-5". They have discontinued the Roman numeral scheme in the latest edition (released this year), but some still use the old way.

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DanBC 13y ago

> This is one of the major flaws in George Orwells’s 1984: When O’Brien laughingly expounds on his vision of “a boot stamping on a human face – forever” Sounds about right. (http://imgur.com/a/IJnR2 http://imgur.com/a/IJnR2)

bhaumik 13y ago

If anyone's curious about the changes in DSM-5 (from DSM-IV) here are the "highlights": http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20t... Very interesting additions/clarifications.

chimeracoder 13y ago

> “caffeine intoxication disorder.” As someone who mostly appreciated the DSM-IV (though recognized its shortcomings), this is my biggest concern with the DSM-V, and why I consider it to be a step backwards in many ways. CAVEAT: My understanding of the DSM-V is based on earlier drafts/non-final editions, so some of these details may be stale, but it appears the general principles that I object to haven't changed. The DSM-IV-TR was very specific with its definitions of "substance abuse" and "substance dependence". My main complaint with the former was the way two of the criteria were poorly worded. It referred to the amount of legal trouble and/or risk that the person took to obtain the drug and could, if very broadly (mis-)interpreted, be used to identify any user of any illegal drug as suffering from "substance abuse" just by definition[0]. This is mostly a quibble about the wording of one detail, though; I think that these were good definitions overall and were more helpful than not. Criticially, the DSM-IV-TR was able to distinguish between casual users of a drug (be it caffeine, alcohol, marijuana, heroin, etc.) and those who actually suffered from "addition" (a term I put in scare quotes because it does not have a medical definition, unlike the words "abuse" and "dependence"). This is a crucial distinction. If you send someone who drinks infrequently but is not an alcoholic to rehab, you are providing treatment for a disorder that they do not have. Thus, you wouldn't be surprised (or concerned) to find their behavior unchanged six months later. You would not consider it a "relapse" if they continued to drink infrequently. Unfortunately, the DSM-V turns this on its head, by allowing "fill-in-the-blank" intoxication disorders. Think of generic classes in Java - they work the same way. Given the name of any drug, you can provide the corresponding disorder - in this case, "caffeine intoxication disorder", or "marijuana abuse syndrome"[1] The problem with the new wording is that it encourages over-diagnosis of mental disorders. Instead of requiring a professional to distinguish between disorders and non-disorders (easy), it lumps all together as disorders, and requires professionals to distinguish between those which require treatment and those which don't (hard). This is not only more difficult medically, but more problematic legally. No doctor or hospital wants to accept the liability of saying that they saw a patient previously diagnosed with a disorder and then determined that they didn't need treatment. This is far worse than simply failing to diagnose a disorder. This may seem like a minor point, but it's not. We've been struggling with issues of overdiagnosis and overtreatment of non-disorders (not just drug-related) for years; in a very subtle way, the DSM-V further entrenches this problem. [0] Incidentally, DSM-V did drop the "legal trouble" criterion. [1] I forget the exact wording of the latter; this was a while ago and I believe they changed it.

ACow_Adonis 13y ago

One is reminded of other fictional works such as American Psycho, by Brett Easton Ellis. These works are valuable to read not because they are overly pleasant, but specifically because they are such transparent and horrific reflections of the inner mental state of the narrator. Such a state is then projected onto the mind of the reader so effectively that the disgust and alienation you feel while reading the book is effectively the same disgust and alienation internalised at all times by the novel's protagonist. In this the DSM-V is another brilliant piece of fictional writing. A world where everything is classified, pathologised, and detached from its context, values, society, and causes. During the entire tome, you are completely separated from any notion of wellness, love, morality, or healthy human beings, with everything classified and filed away like a work-bench with little boxes for every possible failing. It finally hits you as you feel so disgusted and alienated by the conclusion of the novel...that this is specifically because the narrator is so alienated and separated from such realities, and the novel has succeeded perfectly in its goal. To put you in such a tortured, flawed, and erroneous mindset that you now understand completely the flawed and erroneous mindset and worldview of the narrator. Kudos to the author. Another masterpiece.

yuubi 13y ago

"system of repression . . . in which deviance isn’t furiously stamped out . . . but pathologized instead." For instance, https://en.wikipedia.org/wiki/Sluggishly_progressing_schizophrenia https://en.wikipedia.org/wiki/Sluggishly_progressing_schizop...

chaffneue 13y ago

This article is just purple prose nonsense that takes advantage of their audience's natural distrust of information that surrounds the human mind (see the author's reference to multiple benign conditions to discredit the work) and the author's own hang up about some sad end where "human beings are individuated, sick, and alone." From pioneers like Freud to the modern psychoanalysis spectra we have today, I see much of the body of work around human mental states being about classification/categorization, statistical aggregation, symptom/diagnosis tracking and vocabulary. The article is more or less reading a collection of codified medical anomalies and then attributing a singular, malevolent narrative tone to it instead of just reading it for what it is: a standardized professional manual with a strict written style and many collaborators. There's no narration let alone an "unreliable" narrator, there's minimal subjectivity, there are no actors, there's just some observational information presented in a standard way. While I'm aware the DSM has its critics and naff list of non-disorders, I don't believe that committing to basic research and presenting objective findings is a madness that itself belongs in the DSM. What if the goal to this manual is altruistic? What if even one patient benefits from a faster recovery from some mental malaise because of this manual? I'm inclined to say keep researching!

mjn 13y ago
> What if the goal to this manual is altruistic? That doesn't sound at all out of line with a typical dystopian novel plot. :)
- chaffneue 13y ago
  Haha! good point!
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chattoraj 13y ago

The NIMH (National Institute of Mental Health) announced a few months ago that it would be "re-orienting its research away from DSM categories". Even the guys on the inside don't trust it. http://mindhacks.com/2013/05/03/national-institute-of-mental-health-abandoning-the-dsm/ http://mindhacks.com/2013/05/03/national-institute-of-mental...

davidjohnstone 13y ago

One of the criticisms being leveled at the DSM-V here is that "normal" is being negatively defined as the absence of disorder: > DSM-5 seems to have no definition of happiness other than the absence of suffering. The normal individual in this book is tranquilized and bovine-eyed, mutely accepting everything in a sometimes painful world without ever feeling much in the way of anything about it. Positive psychology[1] is a branch of psychology that agrees with this critique, and rather than looking at what goes wrong with people, it looks at what is right about people. There is a book "Character Strengths and Virtues"[2] that is aimed at being the positive counterpart to the DSM, providing a taxonomy of character strengths that have been identified across different times and cultures. 1. http://en.wikipedia.org/wiki/Positive_psychology http://en.wikipedia.org/wiki/Positive_psychology 2. http://en.wikipedia.org/wiki/Character_Strengths_and_Virtues http://en.wikipedia.org/wiki/Character_Strengths_and_Virtues

einhverfr 13y ago
Not only is normal defined as the absence of disorder, but disorders are viewed dimensionally rather than categorically, so to some extent they apply to everybody.
- _delirium 13y ago
  For many disorders, the extent to which they apply on an axis is also, when it comes down to it, defined relative to whether it causes trouble for one's job or not. This is written explicitly into many of the diagnostic criteria, so that the same objective behaviors would be a disorder for a person with one job, where they pose a serious problem to their ability to carry on that occupation, but not for another person with another job, where the behavior is no threat to their livelihood. But this begs the question [1] of whether it's the person or the job that's "at fault" or "abnormal". That's where some of the criticism originates: one allegation is that perfectly normal people are being diagnosed as mentally ill and told they need treatment, when they are maladapted to a job that in fact most humans are maladapted to. In other words, they are within the normal range of human behavior, but treated as mentally ill because their job expects abnormal human behavior. [1] In the precise meaning of the term.

tokenadult 13y ago

I see chimeracoder has already posted a comment here. Maybe I should plunge in, after looking at the "book review" kindly posted here, to comment on psychiatric nosology (classification of disorders) in general. Basis of knowledge disclaimer: I am not a medical doctor, and I have never attended even an undergraduate-level course in psychology. On the other hand, I have been reading extensively about psychology for twenty years,[1] mostly focusing on research on human intelligence and human behavior genetics, and over the years my participation in online discussion networks gained me an invitation to participate in the "journal club" (graduate seminar course) on human behavior genetics at my alma mater. At the behavior genetics seminar, I have met several researchers who have been trying to clean up psychiatric nosology and improve the newly released edition of DSM. The researchers I know locally do NOT like the framework or approach of DSM-5. I'll try to do a layman's justice to their point of view in what I write below. We have discussed before here on HN the blog of the director of the National Institutes of Mental Health, which included a post "Transforming Diagnosis,"[2] casting considerable doubt on the diagnostic approach taken in DSM-5, which was published just before DSM-5 itself was published. Most researchers agree that to develop better understanding of troubles patients experience, and better approaches to treatment, a lot of mental disorders will have to be recategorized (including no longer being categorized as disorders) based on new criteria. That's what the progress of science will look like in this field. It's important to remember that Freudianism was still in vogue when I was young (and constituted most of the higher education in psychology that my parents received in the early 1950s) and psychology and especially psychiatry are STILL undoing some of the harm caused to those disciplines by mistaken ideas from Sigmund Freud. It's easy to tell persuasive stories about what makes people's minds work, but much harder to test those stories with evidence. Neurologists who are interested in science-based improvement of medical practice have commented[3] on DSM-5, and comments of that kind point the way forward to improvement of nosology in psychiatry in the future. Therapists may have to give up their pet "specialities" to recognize the realities of how to help patients. There will surely still have to be new diagnostic tests and new drug treatments developed. The DSM-5 didn't do as well as it ought to have to advance understanding of mental disorders. But its evident faults will prompt further research, and DSM-5 will eventually be replaced by a new edition, one I hope will be based on better science. [1] https://en.wikipedia.org/wiki/User:WeijiBaikeBianji/IntelligenceCitations https://en.wikipedia.org/wiki/User:WeijiBaikeBianji/Intellig... [2] http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml http://www.nimh.nih.gov/about/director/2013/transforming-dia... [3] http://www.sciencebasedmedicine.org/dsm-5-and-the-fight-for-the-heart-of-psychiatry/ http://www.sciencebasedmedicine.org/dsm-5-and-the-fight-for-...

wavesounds 13y ago

"The word “disorder” occurs so many times that it almost detaches itself from any real signification, so that the implied existence of an ordered state against which a disorder can be measured nearly vanishes is almost forgotten. .... Here all pretensions to objectivity fall apart and the novel’s carefully warped imitation of scientific categories fades into an examination of petty viciousness." Or as Richard Feynman coined it: Cargo Cult Science http://en.wikipedia.org/wiki/Cargo_cult_science http://en.wikipedia.org/wiki/Cargo_cult_science Also lets not forget these same people claimed being homosexual was a mental disorder until 1973!

jboynyc 13y ago

Ian Hacking had a great review of the DSM-5 in the LRB earlier this year: http://www.lrb.co.uk/v35/n15/ian-hacking/lost-in-the-forest http://www.lrb.co.uk/v35/n15/ian-hacking/lost-in-the-forest

thucydides 13y ago

Great piece. Two of my favorite substantive critiques: 1. "DSM-5 seems to have no definition of happiness other than the absence of suffering. The normal individual in this book is tranquilized and bovine-eyed..." The DSM does turn mental disease into an entirely negative subject: you're mentally healthy only if you lack any of the listed disorders. The name "Diagnostic and Statistical Manual" does limit the enterprise contained within, but practically speaking, the DSM is the Bible for mental health professionals. It's the document that describes a substantial portion of how to give care to the mentally sick, and no other document has the same stature. And yet their Bible contains nothing at all about mental hygiene or positive practices. Consider how odd that is, how it distorts the mental health professions. In the realm of "physical" health, medical doctors speak with unanimity on every medium imaginable about how you should exercise regularly, eat more fruits and vegetables, etc., to stave off cancer, diabetes, heart disease, and an array of other ailments. How often do you hear psychiatrists talk about the importance of working on your empathy and forgiveness skills? N.B.: doing so will make you happier. Again, cataloguing symptoms is important, but not all-important. DSM sucks all the air out of the room and leads those who study the mind to focus excessively on the neat categorization of symptoms rather than means of staving off mental illness in the first place or of developing admirable virtues like courage, self-discipline, and justice. 2. "On some level we’re to imagine that the American Psychiatric Association is a body with real powers, that the Diagnostic and Statistical Manual is something that might actually be used, and that its caricature of our inner lives could have serious consequences." We know that the caricatures have serious consequences for millions of people, which ought to horrify us. I've seen the consequences of this kind of over-pathologization up close. I've had several criminal clients who've been seriously affected by faulty prison diagnoses of schizophrenia and bipolar disorder. These faulty diagnoses led to the prescription of the powerfully soporific antipsychotic Risperdal, which turned my clients into physically weak zombies, and, for that reason, into victims of sexual assault. Admittedly this is an extreme example, but it amply demonstrates the power of the DSM.

Dylan16807 13y ago
I understand misdiagnosis of many things, but how do you get misdiagnosed as schizophrenic?

morgante 13y ago

I feel pretty stupid for taking so long to realize that this is an actual review of the DSM-5. Up until halfway through, I thought this was indeed a review of brilliantly executed satire in the form of the DSM. Though that itself could actually be a pretty interesting literary form...

fit2rule 13y ago

The thing about the DSM-V is that it is simultaneously a bible, a dictionary, a sales catalog, and an industrial reference manual. As a work of literature, it is the pinnacle of mans' oppression of mankind, categorized, classified. Any single manner by which one might criticize ones fellows, put them in a box, and prepare for delivery: DSM-V has it.

Sagat 13y ago

I have trouble taking psychology and psychiatry seriously. They are the softest of the sciences and mostly based on cultural norms anyway. Consider the fact that homosexuality was labelled a mental disorder in the DSM not long ago. This is evidence that they make it up as they go along.

DanBC 13y ago
> Consider the fact that homosexuality was labelled a mental disorder in the DSM not long ago. It was removed in about 1975. There's plenty of dumb stuff done in many areas of science 40 years ago.

philwelch 13y ago

What I think a lot of people are missing is that the entire notion of mental illness is a hack. The basic definition of any mental illness requires that it interferes with ones ability to live a normal life. Resist the urge to deconstruct that for a second, I'll come back to it. Some people have problems that some type of professional help can enable them to solve. This can range from people who need medication to avoid seeing and hearing things that aren't there to people who need CBT to get out of a self-destructive rut to people who need cosmetic surgery to feel like their body fits their subjective gender. But the United States is full of systems where you need a diagnosis to do anything--bill insurance, prescribe medication, declare someone to have a disability so they can collect income without working. So DSM is a tool for psychologists and psychiatrists to put a code down on a form so the system will let them help people. This is why there's a stipulation that it's only a mental illness if it prevents you from living a normal life. Lots of people have the symptoms of mental illness, just not to such a degree that it warrants intervention. Having compulsive rituals is perfectly normal--compulsively washing your hands until they bleed is not. A good mental health professional will know the difference and only provide a diagnosis when it's necessary. But ultimately the DSM isn't a bedrock of abnormal psychology, it's just a tool psychologists use to make the system let them help people.

001sky 13y ago
The entire notion of mental illness is a hack-Job. That sounds about right.