Psychiatric Bible to Add New Diagnoses: DSM Makeover Process Shrouded in Secrecy

by Karen Franklin, Ph.D.
October 15, 2008
[link to article]

It’s a tried-and-true formula:

Do a quick-and-dirty study or two. Find a huge, perhaps escalating, problem that has heretofore been overlooked. Create a product label (aka diagnosis). And, voila! The drug companies will take it from there. A diagnosis that was once just a twinkle in the eye of a creative researcher becomes reified as a concrete entity.

Over the past couple of decades, the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association has risen from its humble origins to an object of worship, regarded as the absolute scientific truth. Privately, however, many mental health professionals refer to it as a “joke.” That’s partly because of research studies showing that many diagnoses have poor validity in the real world. It’s also because of its many undesirable influences, including internal turf wars, cultural fads, group-think, and outside lobbying. And leading the outside lobbying, of course, is the pharmaceutical industry.

An example of how this process works is the case of shyness. Christopher Lane, an English professor and Guggenheim fellow, shows in his book, Shyness: How Normal Behavior Became a Sickness, how psychiatrists transformed shyness from a normal personality trait into a pathological condition labeled Social Anxiety Disorder. As Lane points out, not only can diagnoses be manufactured out of whole cloth, but their prevalence can be made to rise and fall like the stock market through arbitrary adjustments of the threshold cutoffs. And the DSM has a very low bar for calling something a disorder.

In writing his book, Lane was able to get unprecedented access to internal memos and letters of the American Psychiatric Association’s DSM-III task force. Based on these primary sources, he credits the rise of the DSM from an obscure tract used mainly by state hospital hacks to an international bible to one man – Robert Spitzer – who chaired the task force and handpicked its members from people he considered “kindred spirits.” (Spitzer is perhaps better known among the general public for his controversial stance that gay people could be turned heterosexual through reparative therapy.)

Over the years, the DSM has expanded from just 106 pages to its current 886. (See chart.) The severe mental disorders that once formed the book’s core are still in there. There’s just so much fluff that it’s harder to find them.

And now, the American Psychiatric Association is at it again, working on the fifth edition that is set to launch in May 2012. But this time, perhaps in response to exposes such as Lane’s, there will be no telltale memos and letters to document the process. Task force members are sworn to complete secrecy; they must sign a “confidentiality agreement” prohibiting them from disclosing anything to anyone.

Ironically, even DSM-III architect Robert Spitzer is being excluded this time around. Denied access to task force committee minutes and other information, an angry Spitzer wrote a protest editorial that was rejected for publication by the American Journal of Psychiatry, the official journal of the American Psychiatric Association. (The editorial, “Developing DSM-V in Secret,” is available online.) With prominent psychologist Scott Lilienfeld and others, Spitzer last month called for a petition drive to force the APA to open up the DSM-V revision process to public observation.

No doubt hoping to forestall such a petition drive, the APA just announced that its Assembly of local branch representatives will vote November 18 on an “action paper” that would encourage less secrecy. The vaguely worded paper calls on the APA’s Board of Trustees to “develop policies and processes that balance the need for openness and transparency and the need to protect its intellectual property.” If approved by the Assembly, the action paper will go before the association’s Board of Trustees in December.

The secrecy issue comes amid mounting controversy over psychiatrists’ ties to the drug industry. The U.S. Senate Finance Committee has launched an investigation into whether drug money is compromising the integrity of medical science. Prominent psychiatrist Charles Nemeroff of Emory University, whom critics have nicknamed “Dr. Bling Bling,” is at the center of the probe; he reportedly earned millions of dollars from pharmaceutical companies while promoting drugs to heal depression and other emotional problems.

Not only is psychiatric diagnosis increasingly shaped by and for the pharmaceutical industry, but also in the legal realm DSM diagnoses are often employed pretextually, to accomplish various legal outcomes. With the new revision, partisan groups are advocating for inclusion of highly controversial new diagnoses with far-reaching legal implications.

In high-conflict child custody litigation, for instance, by far the most controversial theory is Parental Alienation Syndrome. Despite the absence of empirical support for this theory, a partisan lobby is pushing for its inclusion. And the battle lines are drawn primarily by gender: PAS is apt to be the first line of defense when a husband is accused in a custody battle of sexually abusing his children.

And no psychiatric diagnoses are conceptually weaker than some that are being used in the service of civilly committing sex offenders, who generally do not have any of the traditional severe mental disorders. The latest, and most farcical of these pseudo-diagnoses is “hebephilia,” or the sexual attraction to teens, which is being aggressively marketed by a small advocacy group.

Other controversial diagnoses being proposed for the DSM-V include Internet Addiction, Relationship Disorder, and Gender Identity Disorder, the latter of which has drawn intense fire from transgender activists. If Big Pharma gets its way, Female Sexual Dysfunction (FSD) could even be a contender.

On the other hand, perhaps all of the hubbub about the revision process and the ties of some psychiatrists to the pharmaceutical industry will encourage the American Psychiatric Association to be a bit more circumspect with new diagnoses, realizing that a massively overmedicated and increasingly cynical public is starting to get fed up.