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01/08/2009

Diagnosing in the Dark: why the DSM should see the light

Homosexuality used to be a mental disorder.  Shyness still is.  So is not being shy. 

The Diagnostics and Statistical Manual - the "Bible of Mental Illness" consulted by psychiatrists - is no stranger to controversy.  What gets classified as a mental illness differs every decade, and impacts millions of lives. 

But a new kind of controversy is surrounding the newest version of the DSM - before it's even been written.  A group of prominent psychiatrists, including previous DSM authors, are saying that the new edition is being written under a cloud of secrecy - which is unscientific, inadvisable, and possibly immoral. 

Without full disclosure of who's writing what, and why, they say, everything from personal prejudice to conflicts of interest could be codified as "best practice."

"(T)his unprecedented attempt to revise DSM in secrecy indicates a failure to understand that revising a diagnostic manual—as a scientific process—benefits from the very exchange of information that is prohibited by the confidentiality agreement," wrote Dr. Robert Spitzer,  who chaired the writing of the DSM II in 1980, in a letter to his colleagues. 

The American Psychiatric Association, according to the LA Times, says that while the deliberations may be secret, the process is transparent - to them - and that psychiatrists working on the DSM are limited to just $10,000 annually in fees from drug companies.  That's prompted a heated discussion on medical blogsabout whether this secrecy is unethical (the doctors writing the new DSM are, presumably, signing confidentiality agreements of their own free will) or practical. 

Art Bohart, author of "How Clients Make Therapy Work" and head of Saybrook'sPsyD program, says that the DSM has always been highly suspect from a Humanistic perspective - and that secrecy only makes matters worse.

"Virtually all of us, if we were brought to the attention of a mental health professional, could get some kind of DSM diagnosis," he says. "DSM has expanded enormously over the years, yet with no evidence that many of the things included are truly 'disorders.' Rather, there have been criticisms that conditions are included so that psychiatrists can bill for "treating" them:  and not because they are scientifically established "disorders."

Limiting the people who create the DSM to $10,000 in fees from drug companies "hardly eliminates a bias in favor of doing things that drug companies will be in favor of," Bohart says. "To have deliberations carried out in secret would seem to fuel those problems."

But while developing the DSM in secret may be a scandal, Bohart emphasizes that the DSM approach as a whole is still problematic for those whose interest in psychology is to help people.

"There is little evidence that diagnosis from the DSM helps do effective psychotherapy," Bohart says.  "DSM diagnosis is based on symptoms. Thus if someone is depressed they are diagnosed with a depressive disorder. This is primitive. It would be the equivalent in medicine if someone had a cough and got diagnosed with 'cough disorder,' or was vomiting and got diagnosed with 'vomiting disorder.'

Nor has the DSM ever been tested against other diagnostic frameworks.

"In this regard humanistic colleagues such as Larry Leitner at Miami University in Ohio, have offered alternative diagnostic systems that are more useful for doing psychotherapy," Bohart says.  "When Larry Leitner tried to get a grant from the National Institute of Mental Health to compare which system, his or DSM, would be of more use to practicing therapists, it was rejected."

Perhaps the real problem with the DSM isn't that it's a secret - but that it's a monopoly. 

Posted at 12:52 AM in

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