The DSM System: How it Really Works

You have to laugh. The current stand-off between the American Psychiatric Association, that sponsors the DSM series, and the National Institute of Mental Health, that sponsors scientific psychiatry, is like two ships passing in the night. Neither group understands what fragile, unstable things psychiatric diagnoses are, riddled with cultural prejudices and tossed in the tide of events. The APA shouts “Science, science, science!” as though they had created a chemistry set. And the NIMH harrunphs about “basic neural pathways,” as though they were within months of figuring out the brain biology of illness.

But first they have to come up with diagnoses that correspond to what people actually have. And neither group gets even a passing mark. In fairness, NIMH hasn’t yet produced its own classification of diagnoses. But next weekend the APA is going to launch DSM-5 at its annual meeting in San Francisco.

What’s the problem here?

The problem is that the current system is a hodgepodge of diagnoses left over from the 19th century, of relicts left over from psychoanalysis, and of people’s bright ideas – people who were powerful enough to punch their bright ideas through.

After the collapse of Freudian psychoanalysis, DSM-3 in 1980 was supposed to provide a beacon of truth. But instead, it has guided psychiatry into the desert, with anecdote and prejudice devoid of scientific rigor.

DSM is a consensus document. This means horse trading. I’ll give you your diagnosis if you give me mine. We didn’t get the speed of light in a consensus conference, and psychiatry’s Achilles heel is that it hasn’t been able to come up with diagnoses in a way that doesn’t look like an international peace conference.

The DSM-5-ers have promised to be “data driven.” Yet it’s like having data-driven astrology, or data on the diagnosis of “hysteria.” The data are meaningless if the thing doesn’t exist.

These diagnoses are the workhorses of the field. Some got in as:

Fad: “Bipolar disorder.” This was the work of a German psychiatrist named Karl Leonhard, who in 1957 conceived the idea of classifying depressions by polarity. That meant some depressions alternated with mania, going up and down; these Leonhard called “bipolar disorder.” Depressions that went only down, or were unipolar, ended up called “major depression” in DSM-3. Leonhard’s work was spread abroad by a clutch of eager disciples.

Thus we have the depression of bipolar disorder as presumably quite different from the depression of unipolar disorder – and requiring separate treatments (“mood stabilizers” for bipolar disorder, “antidepressants” for unipolar disorder). In scientific terms, this makes little sense. The bipolar and serious unipolar depressions are the same depression: Melancholic depression is a good term for it. “Bipolar disorder” is simply serious depression complicated with the occasional episode of mania or hypomania.

Fiat: “Major depression” was the creation of one man in 1980: Robert Spitzer was the autocratic director of the third edition of the DSM that dumped out all the old psychoanalytic concepts – except the “personality disorders” -- and created a slew of new ones.

There is such a thing as depressive illness. Its severe form is called melancholia. Before 1980, psychiatry always had a sense of there being two depressions: melancholia and non-melancholia (called various things, such as neurasthenia, reactive depression, and, in another long-ago epoch, “nerves.” ) DSM-3 abolished these two depressions and lumped them together as “major depression.” This was a huge scientific mistake, as the previous two depressions responded to different treatments.

Fallacy: “Schizophrenia” was the creation of one man, Emil Kraepelin, in the 1890s. Kraepelin was the professor of psychiatry first in Heidelberg then in Munich, arguably the two most prestigious psychiatry posts at that time in the world. Kraepelin’s concept of psychosis (which means the loss of contact with reality in the form of delusions and hallucinations) incorporated the fallacious idea that all patients with chronic psychosis went relentlessly downhill into dementia.

Kraepelin called this concept dementia praecox, or premature dementia, and Eugen Bleuler, the professor of psychiatry in Zurich, christened it in 1908 “schizophrenia.” The concept revolutionized psychiatric diagnosis. Although it went completely against well-known facts of the day, such was the prestige of German professors that people just followed along.

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I’m not being antipsychiatry here. There is such a thing as psychosis, merely that many patients recover, or are stabilized at a high level. They don’t all deteriorate into dementia!

All these diagnoses got into DSM via unscientific routes.

But here’s the thing: Once diagnoses get in, it’s impossible to get them out, because there’s no way to disprove anything in psychiatry. There are other diagnoses that stay around forever: hysteria. This was defeated not by new findings but by politics: the women’s movement disliked it. The whole DSM is highly political.

There is a lesson for our time here: The advocates of these diagnoses, in the present case the big guns pushing DSM-5, are very luminous. The organization pushing the DSM is very puissant: the American Psychiatric Association has lots of money and the power of the pharmaceutical industry behind it. But if you don’t have the right ideas, you’re going to wreak havoc. Millions of patients have received the bogus diagnoses of the DSM system, and the often ineffective drug treatments associated with them. This promises to continue.