GLOBE AND MAIL | June 25, 2008
It’s the dictionary of mental conditions that clinicians turn to, but critics say the science behind the Diagnostic and Statistical Manual (DSM) is flimsy. They say it takes personality traits and turns them into medical conditions regardless of the harm the diagnoses and their accompanying stigmatization might cause.
And, they say, financial relationships between the book’s authors and the pharmaceutical companies call the book’s credibility into question.
Christopher Lane, author of Shyness: How Normal Behavior Became a Sickness, accuses the APA of transforming shyness into a psychiatric disorder with their inclusion and interpretation of social anxiety disorder in the DSM.
“[Social anxiety disorder] did not formally exist before 1980. Two decades and several multimillion dollar promotional campaigns later, it had turned into the third most diagnosed mental disorder in the U.S., behind only depression and alcoholism,” Mr. Lane said. “…The [American Psychiatric Association] is partly responsible for turning normal traits and common behaviours into treatable conditions. You can tell this simply from the number of mental disorders on the books.”
The DSM, first published in 1952, is in its fourth edition. It is 886 pages long and lists nearly 300 disorders – almost three times as many as the first edition, which had 106.
Critics have argued that many disorders in the DSM are cultural or imagined, or don’t constitute disease. Homosexuality was listed in the DSM until 1974, when it was removed following a series of protests at APA annual conferences.
“The very fact that homosexuality was classified for decades as a mental disorder tells us a lot about the DSM,” Mr. Lane said.
Supporters of the DMS say the book simply reflects an incomplete understanding of human brain and behaviour. And, they say, it’s just a small part of the psychiatric process.
“We cannot biopsy a living brain” says Patrick White, president of the Canadian Psychiatric Association (CPA). “The DSM is just the beginning, the assessment of the individual is a multistep process.”
Critics charge that influence from pharmaceutical companies looms too largely over the DSM.
In 2006, the scientific journal Psychotherapy and Psychosomatics published a report outlining undisclosed financial relationships between more than half of the medical experts who authored the 1994 edition of the DSM and pharmaceutical companies. The researchers found that 56 per cent of the 170 experts who worked on the 1994 edition had at least one monetary relationship with a drug maker in recent years.
Diagnosed patients only become eligible for insurance refunds once a mental illness appears in the DSM according to Dr. White.
In an article delving the experts’ financial relationships with pharmaceutical firms, Michael First, psychiatry professor at Columbia University who co-ordinated development of the DSM-IV, told the New York Times, “I can categorically say, and I was there every step of the way, that drug-company influence never entered into any of the discussions, whatsoever.”
The APA has promised full financial disclosure in future DSM editions. It’s unlikely to assuage all doubts.
“There’s very little distance between the drug companies and their paid consultants and researchers, and that’s created a worrisome conflict of interest that’s starting to be a health issue in its own right.” Mr. Lane said. “Such conflicts of interest greatly undermine any presumption that we’re seeing scientific principles at work. If we were, we’d now have an extensive literature on the most worrisome side effects of SSRI and other psychiatric medications.”
SSRIs, selective serotonin reuptake inhibitors, are a class of antidepressants used to treat depression, anxiety disorders and some personality disorders.
The DSM underwent a fundamental facelift in 1980 with the publication of the third edition to emphasize “inter-rater reliability,” which is the likelihood that multiple practitioners will arrive at the same diagnosis. Previously, the book had been based on psychodynamic theory which centres on the interplay between unconscious psychological forces. Since then the APA and CPA have endeavoured to embrace contemporary brain science and take advantage of new neuro-imaging techniques to create a more scientific manual.
“We have become much more sophisticated, we have gone back to biology. … We are biological beings, the brain is a biological thing.”
The DSM’s defenders argue that it would be impossible to collect and communicate mental health statistics without a standard classification of disorder profiles.
“There has to be some sense of order of how we look at symptoms and disorders,” Dr. White said. “Psychiatry has gone fully into mainstream medicine, partly because our means of collecting data and doing research have.”
Dr. White said he doesn’t expect the controversy to go away. He said he welcomes the scrutiny and believes the constant self-examination is good for psychiatry.
“[Criticism] is important; it makes our practice better. … If we lose that, we’re in trouble.”