Volume 18 • Issue 2 • Summer 2018 IJCP

Practitioner Perspective The Validity of the DSM: An overview By Dr. Terry Lynch.

(Johnston). According to Steven Hyman, Insel’s predecessor as director of the National Institute of Mental Health, the creators of the DSM:

“Chose a model in which all psychiatric illnesses were represented as categories discontinuous with ‘normal.’ But this is totally wrong in a way they couldn’t have imagined. What they produced was an absolute scientific nightmare.” (Belluck, 2013).

DSM-IV Task Force lead psychiatrist Allen Frances has spoken of “DSM-5’s flawed process and reckless product”; “discredited and trict adherence to the DSM- psychiatrist Thomas Insel wrote prior scientifically unsound; “the gross S5 would remarkably result in to DSM-5’s publication: incompetence of DSM-5” (Frances, fifty per cent of people supposedly 2013); “deeply flawed”; “untested”. having a so-called “” “While DSM has been described as (Frances, 2012). Frances also wrote: by age 40 (Rosenberg, 2013). A a ‘bible’ for the field, it is, at best, conversation about the DSM is a dictionary, creating a set of labels “More than 50 mental health therefore welcome (McHugh, 2018). and defining each. The strength of professional associations The American Psychiatric each of the editions of DSM has petitioned for an outside review of Association describes the DSM been ‘reliability’ – each edition has DSM-5 to provide an independent as “the authoritative guide to the ensured that clinicians use the judgment of its supporting diagnosis of mental disorders”, same terms in the same ways. The evidence and to evaluate the “the handbook used by health care weakness is its lack of validity.” balance between its risks and professionals in the (Insel, 2013) benefits. Professional journals, the and much of the world” (American press, and the public also weighed Psychiatric Association, 1). Given At a 2005 American Psychiatric in — expressing widespread the authority generally bestowed Association meeting, Insel stated astonishment about decisions upon the DSM, one might expect a that the DSM had “0% validity” that sometimes seemed not only commensurate level of validity as a core DSM characteristic. he problem with the DSM is that in all of its The validity of the DSM-5 T editions it has simply reflected the opinions of Arguably the world’s most influential its writers. Not only did the DSM become the bible mental health organisation, the of , but like the real Bible, it depends on American National Institute of Mental Health’s (NIMH) 2002-2015 director something akin to revelation.

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to lack scientific support but also disorder might be removed from all medical publications, whether to defy common sense.” (Frances, the DSM and some new one journals or books, statements of 2012). included. Believing in the DSM is fact are supposed to be supported much the same as believing in, say, by citations of scientific studies”. No such independent review has the doctrines of the Presbyterian (Angell, 2009). been undertaken. Church. Neither can point to evidence that supports the doctrine American psychologist, social The validity of earlier DSM editions that lies outside the doctrine itself. justice and human rights activist Dr. The 1980 DSM-III is the most When our ideas are supported Paula Caplan is a former professor significant edition, heralding a by evidence, we can regard them of , assistant professor in major shift from psychoanalytic/ as truths. Ideas unsupported by psychiatry and director of the Centre psychotherapeutic perspectives to evidence are fantasies.” (Rowe, for Women’s Studies at the University a biologically-focused approach. 2010, p.130). of Toronto. Her illustrious career Prominent American psychiatrist included a Presidential Citation and a Nancy Andreason wrote: American physician and author Distinguished Career Award from the Maria Angell MD, former Editor-in- Association for Women in Psychology. “Although the authors of DSM- chief of the New England Journal Caplan was an invited consultant III knew that they were creating of Medicine, Senior Lecturer, to two committees involved in the a small revolution in American Department of Global Health & creation of the DSM-IV. In 2014 she psychiatry, they had no idea that Social Medicine, Harvard Medical wrote: it would become a large one and School said: “I resigned from those committees that it would ultimately change the after two years because I was nature and practice of the field.” “Given its importance, you might appalled by the way I saw that good (Andreasen, 2007). think that the DSM represents the scientific research was often being authoritative distillation of a large ignored, distorted, or lied about and Andreasen continued: body of scientific evidence. It is the way that junk science was being instead the product of a complex used as though it were of high quality, “DSM-III and its successors of academic politics, personal if that suited the aims of those in became universally and uncritically ambition, ideology and, perhaps charge. I also resigned because I accepted as the ultimate authority most important, the influence of was increasingly learning that giving on psychopathology and diagnosis. the pharmaceutical industry. What someone a psychiatric label was Validity has been sacrificed to the DSM lacks is evidence. extremely unlikely to reduce their achieve reliability. DSM diagnoses suffering but carried serious risks of have given researchers a common The problem with the DSM is that harm, and when I had reported these nomenclature—but probably the in all of its editions it has simply concerns and examples of harm to wrong one. Although creating reflected the opinions of its writers. those at the top, they had ignored standardized diagnoses that Not only did the DSM become the or even publicly misrepresented the would facilitate research was a bible of psychiatry, but like the real facts.” (Caplan, 2014) major goal, DSM diagnoses are Bible, it depends on something In 1995 Caplan wrote: not useful for research because of akin to revelation. There are no their lack of validity.” (Andreasen, citations of scientific studies to “As a former consultant to those 2007). support its decisions. That is an who construct the world’s most astonishing omission, because in influential manual of alleged According to renowned British- mental illness, I have had an based psychologist and author insider’s look at the process by Dorothy Rowe: roponents of a which decisions about abnormality Pbiologically-slanted are made. As a longtime specialist “Apart from where it deals with perspective argue that in teaching and writing about demonstrable brain injury, the DSM failure to identify cause research methods, I have been is not a valid document. The DSM is common to both many able to assess and monitor the is a collection of opinions. When medical illnesses and truly astonishing extent to which the committee of scientific methods and evidence change their opinions, a mental many “mental illnesses”. are disregarded as the handbook

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is being developed and revised. I could not attempt in a single book ne person had been attending psychiatrists to address the vast array of its Ocontinuously for six years with a diagnosis of biases, examples of its sloppiness “clinical depression”. She was repeatedly told that she and illogical thinking, and just had a biological illness, a brain chemical imbalance – plain silliness. Mental disorders which incidentally has never been verified to exist in are established without scientific any human being – and that her psychiatrists would basis or procedure.” (Caplan, 1995, xv, 90). eventually find the right drug combination.

Paula Caplan cites psychologist wrote one. None helpful.” (Frances, the arbitrary figure of five.” Lynne Rosewater, who participated in 2017). DSM-5 Task Force vice-chair Carlat: “But why did you choose a DSM-III committee: American psychiatrist Darrel Regier five and not four? Or why didn’t you wrote: “Mental disorder definitions choose six?” “They were having a discussion . . . are almost impossible to test.” Spitzer: “Because four just seemed for a criterion about Masochistic (Regier, 2012). like not enough. And six seemed like and Bob too much.” Spitzer’s wife says ‘I do that DSM Depression criteria Robert Spitzer “smiled impishly” as sometimes’, and he says, ‘Okay, Problems arise even within DSM he uttered the last sentence. (Carlat, we’ll take it out’”. (Caplan, 1995, sections generally considered 2010, p. 53). p. 91). uncontroversial. In my best-selling British psychologist James Davies book Beyond Prozac I wrote: also interviewed DSM-III lead Robert (Bob) Spitzer was the lead psychiatrist Robert Spitzer. Spitzer psychiatrist of the DMS-III Task “Why did the American Psychiatric having admitted that no biological Force. Psychologist Renee Garfinkle Association select five criteria abnormalities had been identified also attended DSM-III committee as the magic figure? What is in any psychiatric disorder, Davies meetings. She subsequently said: so different between a person asked, “So without data to guide you, who meets six criteria — and is how was this consensus reached?” “The low level of intellectual effort therefore diagnosed as having a Spitzer replied: was shocking. Diagnoses were Major Depressive Episode and “We thrashed it out basically. We developed on the majority vote on needing antidepressant treatment had a three-hour argument. There the level we would use to choose — and one who meets four would be about twelve people sitting a restaurant. You feel like Italian. criteria, and therefore receives no down at the table...and at the next I feel like Chinese. So let’s go to psychiatric diagnosis or treatment? meeting some would agree with the a cafeteria. Then it’s typed on a Why five criteria? Why not three? inclusion, others would continue computer”. (LeGault, 2006, p. 91). Or seven? How valid are these arguing...if people were still divided. criteria?” (Lynch, 2001, p.81). the matter would be eventually “Mental disorder” decided by a vote.” (Davies, 2013, The centrality of “mental disorder” Nine years later, American pps 22, 29, 30). to the DSM is illustrated in its name psychiatrist Daniel Carlat put similar – The Diagnostic and Statistical questions to Robert Spitzer, lead “Biology never read that book” Manual of Mental Disorders. One psychiatrist of the 1980 DSM III Task A peculiar situation pertains in might assume that this term’s Force, the psychiatrist responsible for relation to psychiatry and the DSM. meaning would be without ambiguity. introducing these criteria: Mainstream psychiatry has long Aforementioned psychiatrist Allen Carlat: “How did you decide on asserted that the experiences and Frances – lead psychiatrist of the 5 criteria as being your minimum behaviours understood as “mental DSM-IV Task Force – said in a 2010 threshold for depression?” illnesses” are fundamentally interview: “There is no definition of a Spitzer: “It was just consensus. biological. The virtual absence of mental disorder. It’s bullshit. I mean, We would ask clinicians and any evidence verifying these claims you just can’t define it.” (Greenberg, researchers, ‘How many symptoms paints a different picture – as does 2012). In a conversation do you think patients ought to have the absence of characteristic physical with me, Frances wrote: “I’ve read before you give them a diagnosis of examination findings and diagnostic 50 definitions of mental disorder/ depression?’ And we came up with laboratory/radiological tests, which

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One person had been attending common assertion regarding so-called “mental psychiatrists continuously for six A disorders” is that they are medical conditions. years with a diagnosis of “clinical This claim has been made so widely and for so long depression”. She was repeatedly that it is generally assumed to be an established fact. told that she had a biological illness, a brain chemical imbalance – which incidentally has never been verified to are never carried out to diagnose “The problem that we’ve had in exist in any human being – and that “mental illness”, only to exclude dealing with the data that we’ve her psychiatrists would eventually known organic disease, check drug had over the five to 10 years since find the right drug combination. At our levels and check bodily functions, we began the revision process first meeting, a significant narrative given the potential for drug toxicity. of DSM-5 is a failure of our emerged involving major parental Proponents of a biologically-slanted neuroscience and biology to give attachment problems and loss of perspective argue that failure to us the level of diagnostic criteria, selfhood since early childhood. This identify cause is common to both a level of sensitivity and specificity narrative, known to be associated many medical illnesses and many that we would be able to introduce with depression, previously went “mental illnesses”. However, the into the diagnostic manual”. unnoticed, unexplored, unresolved. correct categorisation of biological (Belluck, 2013). The second client had attended illness depends not on causation but her GP on three separate occasions, the presence of verified biological De-emphasising psychological- and was told each time that she abnormalities – pathology. The cause mindedness had “clinical depression” and of many cancers is not known, but The DSM is akin to a distorted radar that medication was the answer. so established is the pathology system, set up to pick up certain Within these exchanges, a raft of of cancer that one will rarely hear aspects of human experience and emotional and psychological issues questioning of the centrality of behaviour and miss others, and to went unnoticed and unaddressed, biological pathology – e.g. cancer interpret these experiences and including considerable trauma, cells – to cancer. behaviours in ways that exclude rejection and abandonment issues, A corresponding fundamental other often more legitimate ways of selfhood reduction, much unfinished weakness – the lack of scientific understanding these experiences business, learned helplessness and verification of biological pathology and behaviours. In his 2010 book, powerlessness, all of which fed into – surfaces throughout the DSM-5. psychiatrist Daniel Carlat wrote of the experiences and behaviours The virtual absence of reference to the DSM: labelled as “clinical depression”. biology within the DSM-5 has been highlighted by the aforementioned “It has drained the color out of the The People Behind DSM-5 Thomas Insel MD: way we understand and treat our According to the American Psychiatric patients. It has de-emphasized Association, which produces and “As long as the research psychological-mindedness, and publishes the DSM: community takes the DSM to be a replaced it with the illusion that bible, we’ll never make progress. we understand our patients when “The DSM-5 development process People think that everything has all we are doing is assigning them has involved not only psychiatrists, to match DSM criteria, but you labels.” (Carlat, 2010, p. 60). but also experts with backgrounds know what? Biology never read that in psychology, social work, book.” (Belluck, 2013). In my work in mental health, I psychiatric nurs¬ing, pediatrics, regularly encounter people given and neurology. DSM-5’s Task By 2013, the National Institute various DSM diagnoses, core Force and 13 Work Groups include of Mental Health had all but aspects of whose stories have been more than 160 mental health and abandoned the DSM-5, “re-orienting largely or completely missed. On the medical profession¬als who are its research away from DSM day of writing this, two such clients leaders in their respective fields. categories”. (Insel, 2013). The attended me. In both cases the The selection of such a diverse lack of biological verification has diagnosis happened to be “clinical group of professionals means that been acknowledged by the Chair depression”, but I regularly encounter a multitude of viewpoints is being of the DSM-5 Task Force, American this phenomenon across the range of considered in each decision”. psychiatrist David J. Kupfer MD: psychiatric diagnoses. (American Psychiatric Association, 2)

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However, nearly 100 of the 160- plus Task Force and Work Group ather than embrace the DSM, I encourage the members were psychiatrists. Less Rcounselling professions to press for trauma-informed than half this figure – 47 – were responses, within which experiences and behaviours are psychologists; just one social worker, accepted and addressed in their own right, and no psychotherapist/counsellor. The control centre within the DSM-5 was the American Psychiatric for counsellors. The medical model Following publication of the DSM-5, Association-appointed Task has long been primarily a biological the Division of Clinical Psychology Force, consisting of 35 members. model. I would caution against of the British Psychological Society Both chair and vice-chair were accepting without question the issued a Position Statement psychiatrists. The remaining 33 profoundly significant “philosophical calling for “a paradigm shift” away members included 25 psychiatrists, assumption that mental disorders from a “‘disease’ model”. (British 3 psychologists and not a single are medical conditions”. Psychological Society, 2013). psychotherapist, counsellor, social Many authoritative medical The words of Louise Armstrong, worker, or occupational therapist. sources do – wrongly – claim author of many books including The emergence of a medicalised that psychiatric diagnoses are Kiss Daddy Goodnight – a ground- approach with the DSM is therefore known brain disorders. The highly breaking book on incest – are hardly surprising. influential US National Institute accurate: of Mental Health (mis)informs its “Mental disorders” as medical readers that “mental illnesses “To read about the evolution of conditions are disorders of the brain”, and the DSM is to know this: The DSM A common assertion regarding so- “Through research, we know is an entirely political document. called “mental disorders” is that that mental disorders are brain What it includes, and what it they are medical conditions. This disorders”. (National Institute of does not include, is the result of claim has been made so widely Mental Health). intensive campaigning, lengthy and for so long that it is generally If psychiatric diagnoses were negotiating, infighting and power assumed to be an established verified biological disorders, they plays.” (Le Gault, 2006, p. 91). fact. Eugene McHugh quotes a would appear within authoritative 2014 book which refers to “the comprehensive lists of brain and Rather than embrace the DSM, philosophical assumption that neurological disorders. All of I encourage the counselling mental disorders are medical the major comprehensive such professions to press for trauma- conditions”. (Dailley, 2014 p. 15). lists I have reviewed include no informed responses, within which This book’s authors referred to two psychiatric diagnosis as a known experiences and behaviours are major underpinning philosophical brain disorder, including a sister accepted and addressed in their changes within the DSM: organisation of the National own right, rather than repackaged as Institute of Mental Health. (National “mental disorders” within a system “The first philosophical change Institute of Neurological Disorders whose “bible” is utterly lacking involves a shift in focus from and Stroke). validity. phenomenological interpretations (i.e., symptom identification Conclusion and behavioral observations–a The experiences and behaviours References medical model) to identifiable diagnosed as various “mental pathophysiological origins (i.e. disorders” are real and valid. The functional changes associated interpretation of these as primarily American Psychiatric Association, 1. DSM-5: Frequently asked questions. with or resulting from a disease or biological entities within the DSM Retrieved from https://www.psychiatry. injury–a biological model”. (Dailley, framework is not valid, fostering org/psychiatrists/practice/DSM/ 2014 p. 17). a dominant modus operandi that feedback-and-questions/frequently- may have prompted global trauma asked-questions I was struck by aspects of this expert psychiatrist Bessel van American Psychiatric Association, 2. The passage. Published by the American der Kolk to create a video entitled people behind DSM-5. Retrieved from Counseling Association, this book is “Psychiatry must stop ignoring file:///C:/Users/info/Downloads/APA_ written by experienced counsellors trauma”. (van der Kolk, 2015). DSM_People-Behind-DSM-5%20(7).pdf.

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Andreasen, A. (2007). DSM and the Minton, C.A. (2014). DSM-5 Learning National Institute of Mental Health. Death of Phenomenology in America: An Companion for Counselors. Alexandria, Brain basics; Introduction. Retrieved Example of Unintended Consequences. Va: American Counseling Association. from https://www.nimh.nih.gov/health/ Bulletin. 2007 Jan; 33(1): Frances, A. (2012, 3, 12). DSM-5 Is educational-resources/brain-basics/ 108–112. Retrieved from https:// a Guide, Not a Bible: Simply Ignore brain-basics.shtml. www.ncbi.nlm.nih.gov/pmc/articles/ Its 10 Worst Changes. Huffington Regier, D.A. (2012). Diagnostic Threshold PMC2632284/. Post. Retrieved from https://www. Considerations for DSM-5. In Kendler, Angell, M. (2009). Drug companies huffingtonpost.com/allen-frances/DSM- K.S. & Parnas, J. (Eds.), Philosophical & doctors: A story of corruption. New 5_b_2227626.html Issues in Psychiatry II: Nosology (pps. York review of books (2009, 15, 1). Davies, J. (2013). Cracked: Why 285-297). : Oxford University Press. Retrieved at http://www.nybooks.com/ psychiatry is doing more harm than good. articles/2009/01/15/drug-companies- London. Icon Books Ltd. Rosenberg, R. (2013). Abnormal is the doctorsa-story-of-corruption/. new normal: Why will half of the U.S. Frances, A. (2013, 1, 23). Price Gouging: population have a diagnosable mental Belluck P, Carey, B. (May 6, 2013). Why will DSM-5 Cost $199 a Copy? disorder? Slate, Health and Science. Psychiatry’s guide is out of touch with . Retrieved from Retrieved from http://www.slate.com/ science, experts say. New York Times. https://www.psychologytoday.com/us/ Retrieved from http://www.nytimes. articles/health_and_science/medical_ blog/DSM5-in-distress/201301/price- com/2013/05/07/health/psychiatrys- examiner/2013/04/diagnostic_and_ gouging-why-will-DSM-5-cost-199-copy new-guide-falls-short-experts-say.html statistical_manual_fifth_edition_why_ Frances, A. (2017, 10, 13). Twitter British Psychological Society, Division will_half_the_u_s_population.html conversation. Retrieved from. https:// of Clinical Psychology. (2013) Position Rowe, D. (2010). Why We Lie, London: twitter.com/search?l=&q=Ive%20 statement on the classification of Fourth Estate. read%2050%20defts%20of%20 behaviour and experience in relation mental%20disorder%20%22Ive%20 van der Kolk, B. (2015). Psychiatry must to functional psychiatric diagnoses, read%2050%20defts%20of%20 stop ignoring trauma. YouTube. Retrieved “Time for a Paradigm Shift”. Retrieved mental%20disorder%22%20 from http://bigthink.com/think-tank/ from https://www.madinamerica.com/ from%3AAllenFrancesMD&src=typd dr-bessel-van-der-kolk-psychiatry-has-a- wp-content/uploads/2013/05/DCP- long-stubborn-history-with-trauma/ Position-Statement-on-Classification.pdf Greenberg, G. (2012, 10, 27). Inside the battle to define mental illness. Wired Canadian Mental Health Association. magazine. Retrieved from https://www. Fast facts about mental illness. wired.com/2010/12/ff_DSMv/ Retrieved from https://cmha.ca/about- Dr. Terry Lynch cmha/fast-facts-about-mental-illness. Insel T. (2013, 4, 29). Transforming diagnosis. National Institute of Mental Carlat, D. (2010). Unhinged: The trouble Health. Retrieved from https://www. Terry Lynch is a mental health with psychiatry—a doctor’s revelations nimh.nih.gov/about/directors/thomas- professional, physician, about a profession in crisis. London: insel/blog/2013/transforming-diagnosis. psychotherapist, best-selling mental Free Press. shtml. health author, provider of recovery- Caplan, P.J. (1995). They say you’re Johnson, R. The Role of Neuroimaging oriented mental health service. He crazy: how the world’s most powerful in Psychiatry and Medicine. is a member of the Expert Group psychiatrists decide who’s normal. Retrieved from https://www.tomf.org/gd- on Mental Health Policy that New York: Addison-Wellesley Publishing Company. resources/downloads/Johnson.pdf. formulated A Vision for Change (2006) – Ireland’s official mental Caplan, P.J. (2014, 2, 17). The great LeGault, M. (2006). Think!: Why Crucial health policy document. He is also ‘crazy’ cover-up: Harm results from Decisions Can’t Be Made in the Blink of rewriting the history of DSM”. Mad in an Eye. New York: Threshold Editions. a member of the Implementation America blog. Retrieved from https:// Lynch, T. (2001). Beyond Prozac. Dublin: Group for Avision for Change (2006- www.madinamerica.com/2014/02/ Marino. 2009), The Second Monitoring great-crazy-cover-harm-results-rewriting- McHugh, E. (2018). A conversation on Group for A Vision for Change history-DSM/ DSM-5 and its usefulness in counselling (2009-2012), and the Irish Health Cosgrove, L. (2009). Developing and psychotherapy. Irish Journal of Service Executive (HSE) Expert unbiased diagnostic and treatment Counselling and Psychotherapy, vol 18 Advisory Group on Mental Health guidelines in psychiatry. N Engl J Med issue 1, pps 21-25. (2006-8) 2009; 360:2035-2036. Retrieved from National Institute of Neurological http://www.nejm.org/doi/full/10.1056/ Disorders and Stroke website. For further information visit NEJMc0810237 “Disorders”. Retrieved from https://www. www.drterrylynch.com Dailley, F.S., Gill, C.S., Karl, S.L., & Barrio ninds.nih.gov/Disorders

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