Requiem for DSM

Requiem for DSM

Almost 2 decades ago, when I graduated from psychiatric residency, DSM-IV was published. You will receive this letter along with, I’m sure, the spanking new shiny edition of DSM-5. I have one wish for you. When 20 years and another generation pass, I hope this will be the last of the DSMs. My wish is that in one more generation, our profession will learn to go beyond DSM to the truths of science.

When I graduated a generation ago, I accepted DSM-IV as if it were the truth. I trusted that my elders would put the truth first, and then compromise for practical purposes where they had no truths to follow. It took me 2 decades to realize a painful truth, spoken now frankly by those who gave us DSM-III when Ronald Reagan was elected and DSM-IV when Bill Clinton was president: the leaders of those DSMs don’t believe there are scientific truths in psychiatric diagnosis—only mutually agreed upon falsehoods.1 They call it reliability.

It might not have been so bad if, as the framers of DSM-III wished, reliability had been a way station to validity. First, let’s agree on what we call things, then we can study them better and change the definitions to get gradually closer to the truth.

That’s what leaders such as Harvard’s Gerald Klerman claimed in the 1970s.2 Robert Spitzer, who headed the DSM-III task force, may have believed this idea, too, when he published the Research Diagnostic Criteria in 1978 with the leaders of the famed Washington University, St Louis, department of psychiatry.3 After about a decade or two of research, they provided their best available research-supported diagnostic criteria for about 2 dozen psychiatric diagnoses.

This was the high-water mark of science in American psychiatry.

But immediately the project went awry. Spitzer used the Research Diagnostic Criteria as the basis for DSM-III. He convened his task force work groups, and a dozen diagnoses became a hundred. He then took the results of the task force to the American Psychiatric Association (APA) assembly (mostly psychoanalysts), which is equivalent to the president sending a bill to Congress. Diagnoses became fruitful and multiplied. The Board of Trustees of the APA had to finalize and approve DSM-III. Somewhere along the line, 2 dozen diagnoses became 265 disorders (not modifiers), without a single piece of new scientific evidence for the other 241.

I suggest you read new historical books that carefully study the minutes of DSM-III task forces and other documentation.4,5 You’ll understand why about 90% (241 of 265) of DSM-III diagnoses are unscientific, and you’ll also understand how even the poor 2 dozen that had decent scientific evidence were distorted and deformed.

Take major depressive disorder—a meaningless term. Have you ever wondered why it is “major”? The historian Edward Shorter describes how the initial goal had been to include severe depression as a scientifically valid psychiatric diagnosis, since so many milder depressive presentations (which used to be called “neurotic depression”) can happen solely in relation to the stresses of life or perhaps because of a personality disposition. In either case, these mild chronic depressive/anxiety presentations (which also used to be called “community nervousness”) are quite different from the severe episodes of depression that begin and end, and alternate with long periods with little or no depression.

These severe episodic depressions were seen before DSM-III as part of manic-depressive illness, in contrast to neurotic depression, which was seen either as a personality state or as a reaction to the stresses of life only.6,7 On the basis of genetic and course studies, the Washington University researchers agreed with Kraepelin’s German critic, Karl Leonhard, that the severe recurrent depressive episodes are different from recurrent mania alternating with depression, so they took the view that the first condition should be called “unipolar” depression and the second “bipolar” disorder.8


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