University of Toronto historian of psychiatry Edward Shorter has written a fascinating article in the Wall Street Journal on the history of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (APA). The article comes in the wake of controversy over the forthcoming 5th edition of the book, which is used by psychiatrists and many psychologists to diagnose the particular kinds of disorders from which their patients and clients suffer.
Shorter declares at the start of the article that “Psychiatry seems to have lost its way in a forest of poorly verified diagnoses and ineffectual medications.” In the 1950s, the diagnostics terms used by psychiatrists were often the same as those used colloquially by their patients — “a case of the nerves,” or “nervous breakdown.” Now, Shorter says, “A patient with the same symptoms today might be told he has “social anxiety disorder” or “seasonal affective disorder.” The increased specificity is spurious. There is little risk of misdiagnosis, because the new disorders all respond to the same drugs, so in terms of treatment, the differentiation is meaningless.”
Shorter reviews the well-known story of Robert Spitzer who, unhappy with the psychhoanalytic connotations of many of the diagnostic terms used as late as the 1970s, replaced them in the 3rd edition of the DSM with new terms, that presumably focused strictly on symptoms rather than on presumed unconscious conflicts advanced by the Freudians. Thus “depressive neurosis” was converted to “major depression,” which was distinguished form “bipolar disorder” and so on. Many compromises were made with the still-powerful Freudian establishment, however, and the result was a mishmash of syndromes and disorders about whose reality there was little more consensus than there had been about their predecessors.
In addition, as new and lucrative psychopharmaceuticals began to proliferate, so did new conditions, generating a demand for more drugs, and so on. As Shorter puts it:
In the late 1980s, the Prozac-type agents began to hit the market, the “SSRIs,” or selective serotonin reuptake inhibitors, such as Zoloft, Paxil, Celexa and Lexapro. They were supposedly effective by increasing the amount of serotonin available to the brain.
The SSRIs are effective for certain indications, such as obsessive-compulsive disorder and for some patients with anxiety. But many people believe they’re not often effective for serious depression, even though they fit wonderfully with the heterogeneous concept of “major depression.” So, hand in hand, these antidepressants and major depression marched off together into the sunset. These were drugs that don’t work for diseases that don’t exist, as it were.
The draft of the new edition does little to solve these problems.
DSM-V accelerates the trend of making variants on the spectrum of everyday behavior into diseases: turning grief into depression, apprehension into anxiety, and boyishness into hyperactivity.
If there were specific treatments for these various niches, you could argue this is good diagnostics. But, as with other forms of anxiety-depression, the SSRIs are thought good for everything.
Shorter concludes that:
What the discipline badly needs is close attention to patients and their individual symptoms, in order to carve out the real diseases from the vast pool of symptoms that DSM keeps reshuffling into different “disorders.” This kind of careful attention to what patients actually have is called “psychopathology,” and its absence distinguishes American psychiatry from the European tradition.