The fanfare surrounding the publication of DSM-5 presents the manual as psychiatry’s bible, a diagnostic decree that clinicians rely on and abide by. Such reception highlights the deficiency of public understanding of mental disorders and their treatment. Last week we asked Liah Greenfeld what she’d most want to convey to the public to help correct that misunderstanding, and below, Richard Noll, author of American Madness: The Rise and Fall of Dementia Praecox, takes on the same question.
“The public here believe in drugs and consider prescription as the aim and end of medical skill,” complained Swiss-émigré neurologist Adolf Meyer in August 1894, “whereas in Germany and in many other places, the people regard the drugs as quite as great an affliction as the disease itself.”
The same is true today. Indeed, since the publication of DSM-III in 1980, even more so.
Since the dawning of the Age of Prozac twenty-five years ago, we have consensually adopted a culture of surveillance medicine which reflexively invokes psychiatric medications as the first-line mechanism of self-mastery and social control for our children, our soldiers, our behavioral deviants, and our selves.
The automatic expectation of a prescription following a DSM diagnosis, usually rendered (perhaps 80 percent of the time) by a primary care physician, clinical nurse specialist, or physician assistant after a 15-minute chat, is so commandingly reinforced by the media and the medical profession that we cannot help but be seduced by the illusion that most of the hundreds of mental disorders in DSM or ICD are “diseases” like any others.
But everyday people have no interest in the philosophical distinction between a DSM or ICD mental disorder and a biological disease concept because the usual treatment they receive for each is medication.
Despite the Sturm und Drang of the psychiatric and media elites concerning low diagnostic reliability rates and the political process of creating and eliminating mental disorders, perhaps less than 10 published studies have been done in the past 33 years to determine how the DSM diagnostic criteria are actually being applied by the hundreds of thousands of medical and mental health professionals in North America who must use them in their jobs. Is the manual even relevant for clinical judgment?
For those of us who work in non-elite everyday clinical settings, these few studies support our daily observation that the exact DSM checklist criteria are rarely followed in diagnosis. DSM diagnoses are regarded merely as bureaucratic codes necessary for insurance reimbursement. For decades, in the trenches of actual medical and mental health practice in non-elite settings, each new edition of DSM has mostly been greeted as some sort of odd communiqué from an irrelevant fairyland.
But the DSM effect on human lives is dramatic. Justification is provided for the widespread misapplication of drug therapies for millions of people who, as collateral damage, now suffer needlessly from side effects and withdrawal symptoms. Symptom relief, if it occurs, is often temporary and mild. Psychosocial factors, especially in children and adolescents, are often ignored. But this reflects the implicit cognitive categories of our historical epoch: in a radically biological psychiatry there can be no epistemic space for the unique individual circumstances or personal context in which symptoms arise.
Neither DSM-5 nor ICD-10 reflects the wisdom of centuries of clinical observation, deep phenomenological understanding, or biomedical research in psychiatry. All mental disorders are not created equal.
Indeed, there is only a small subset of the hundreds of DSM mental disorders which serve as useful heuristics for clear biomedical conditions: schizophrenia, bipolar I disorder (in post-pubertal adolescents and adults, only rarely in children), obsessive-compulsive disorder, autism, dementia, panic disorder, and a presumed small fraction of those so loosely diagnosed with ADHD. Not included in DSM-5 are melancholia (a severe endogenous depression) and catatonia. For some, future treatments may target the endocrine system, the immune system, the microbiome, and other novel “whole body” physiologies. Let’s continue to deepen our understanding of genes, receptors, neurotransmitters, and brain circuits, but let us also widen our imagination to explore other medical hypotheses.
Whether the hundreds of remaining DSM mental disorders will continue to fall under the jurisdiction of psychiatrists as biomedical specialists within general medicine is doubtful. Other primary care medical specialties and non-medical professions already perform most of those services. Most of these conditions respond well to empathy and effortful changes in diet, exercise, cognition, and behavior. None of these actual remedies comes in pills.
Within the Moloch of our current managed care health system, there is little time—or regard—for the deeply felt personal narrative of a suffering individual. Even primary care physicians no longer enter the treatment room and make eye contact or shake the hand of the patient—they sit and click away into their laptops as they follow an algorithmic ritual of data collection. We have no choice but to tolerate this in doctor-patient interactions in our society. No wonder that all we expect from our physicians and psychiatrists is a quick DSM diagnosis and a prescription. Truthfully, within the current system, they can provide little else for us.
But we, as patients, share some blame in this process. Even if our “mental disorders” are not biological disease concepts, we want a diagnosis. We want a structured narrative that puts our suffering into a larger context, a story that unites us with an imagined community of other souls suffering in the same way. Disease concepts are the stories we seek.
We have forgotten that life is hard, that we suffer and are sad, and that these are not (necessarily) diseases. DSM-5, despite its many merits, may only encourage our amnesia.