Peter Reiner of the Neuroethics & Law Blog points to the impending arrival of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or as it will be commonly known, the DSM-V. DSM, in its various editions, is generally treated as the bible of psychiatry, providing diagnostic criteria for a host of mental maladies from the common, such as depression, to the bizarre, such as trichotillomania.
Readers of this site may know that the DSM is relevant to a number of fields of legal practice, including criminal law, tort practice, workers compensation, and increasingly employment law. If nothing else DSM often provides fodder for cross examination of experts, but in some cases it interacts with the law more directly. For instance, whether a person is psychiatrically “disabled” within the meaning of the Americans With Disabilities Act, or an insurance policy, may turn on whether that person’s problems can be summarized through a DSM diagnosis. Revisions to past editions of DSM have even had social and political ramifications in the culture at large. Arguably the removal of “homosexuality” as a form of mental illness in the 1970s contributed, in its small way, to greater acceptance of gay people in American culture.
Like Dr. Reiner, I find one aspect of the revision process troubling. It’s being conducted in secret, and the revisionists are being held by the American Psychiatric Association to confidentiality agreements. The APA has justified this a couple of grounds: first that it allows the committee to work undistracted by public comment from fellow scientists; and second that it prevents members from accepting outside work, such as casebook writing and other assignments, with an eye toward money. After all, “The Doctor Who Wrote the Book On Binge Eating” could make a killing on the Oprah Winfrey Show.
While I’m not a scientist, the secrecy does strike me as bad science, and bad policy. I’d never argue that laypeople, for instance lawyers, should have their comments considered by the APA, but there are many, many psychiatrists, non-psychiatrist MDs, scientists from other disciplines, and psychologists who could provide valuable criticism or validation of the work before it’s plopped onto the public. While I’m also sure that the drafters are ethical, experts of the highest order, and would never commit misconduct, stranger things have happened. And there may even be a few laypeople who have thoughts that might be helpful. Taking homosexuality as an example, there are many people who have non-disabling, non-criminal sexual hangups who might have useful opinions about the fact that “sexual fetishes” are still classified as a form of mental illness.
Make no mistake, the DSM-V will change more than the practice of psychiatry, in ways subtle and profound. Whether the secrecy with which it’s being drafted will contribute to that change is something we won’t know, until the cat is already out of the bag.
Edit: 12/24/2008 Adam Kolber was kind enough to point out that I had attributed the Neuroethics post to him, when in fact its author is Peter Reiner. I have edited this post to reflect that.
7 Comments
I took a law and psychiatry class from Dr. Alan Stone, who sat on one of the committees framing one of the iterations of the DSM. At the time, I had recently read Susan Faludi’s Backlash. (Honesty compels me to admit that my motives were carnal, though it would up being a fascinating book, even though I did not agree with a lot of it.) Anyway, in the class, I questioned Dr. Stone about some of the claims that Faludi makes — basically that the process of selecting and defining disorders for inclusion in the DSM are rather unscientific. (As I recall, the example was a female committee member saying “oh, but I do that,” leading the group to conclude that the thing could therefore not be part of a pathology). Dr. Stone was willing to discuss the process, but was rather notably unable to offer a convincing explanation of why I should view the selection process as principled rather than idiosyncratic.
The thing is, no matter how much they dress it up and academicize it and put this and that policy in, the fact remains that this ain’t science, it is educated opinion at best, and frequently, judging from history, rank prejudice or lemming-like cult fashion train thinking at worst. And the fact that is shows up on a legal blog, because it has such immense legal impacts, pretty much undercuts the futility and danger of the whole enterprise.
If it were actually scientific, it might have real value in terms of justice. As a codification of opinion and prejudice and current fad, it has quite the opposite, no matter what the process used to develop it. The thing itself is wrong, no matter how derived.
DSM III (in my opinion) was the best version that was published, and contained true psychiatric disorders. It is nowhere near as thick as DSM IV and DSM IV-TR (text revision). DSM-IV and DSM IV-TR appear to greatly expand the number of psychiatric diagnoses. A possible explanation for this great expansion is to increase the number of diagnostic codes for the pecuniary interest of the psychiatric profession. There is no way that dozens of “new” disorders suddenly cropped up in the time that DSM III was first published to the time DSM IV superseded it.
Could the secrecy involve Big Pharma, which also stands likely to gain financially if the scope of use for psychiatric drugs is expanded?
It’s worth listening to this NPR “This American Life” program about how homosexuality was reclassified in the DSM-IV:
http://www.thislife.org/Radio_Episode.aspx?episode=204
Truly enlightening.
If you listen, you’ll note that the change wasn’t based on any new developments in scientific understanding, any surveys, any new hypothesis, any tests, any research…just pure social policy as decided by a select, highly focused and self-interested small group of folks in lab coats. Their revision of the DSM-IV was subsequently relied on by the SCOTUS in Lawrence v. Texas and has impacted what may and may not be declared illegal in this country. If they had not made their revision based on a change in social understanding (emphatically not scientific understanding), it is possible if not probable that Lawrence v. Texas would have gone the other way.
…Which isn’t the typical understanding of how a democratic republic is supposed to work, but YMMV.
As a clinical psychologist I’m frustrated by the lack of peer review on the DSM V. Describing the closed method of it’s development and design as “bad science and bad policy” borders on generous.
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