Menus Subscribe Search

Follow us


dsm-dump

(ILLUSTRATION: LASSE KRISTENSEN/SHUTTERSTOCK)

Should We Dump the DSM?

• May 10, 2013 • 6:00 AM

(ILLUSTRATION: LASSE KRISTENSEN/SHUTTERSTOCK)

Gary Greenberg’s new book skewers the inner workings of the DSM just three weeks before the latest version is scheduled to be released.

Editor’s Note: The post originally appeared on The Fix, a Pacific Standard partner site.

On May 22, the American Psychiatric Association will release the fifth version of the Diagnostic and Statistical Manual of Mental Disordersthe DSM-5. The last version, the DSM IV, was published in 1994 and has provided the clinical terms for diagnoses that allow for insurance payments, treatment costs, and public support for such afflictions as Asperger’s and grief—all of which, among a host of established disorders, are set to be altered by the new version.

Last week, Blue Rider Press published Gary Greenberg’s The Book of Woe: The DSM and the Unmaking of Psychiatry, a powerful critique of the entire DSM methodology. Greenberg is a practicing psychotherapist who also authored Manufacturing Depression: The Secret History of an American Disease and The Noble Lie. He has been referred to as “The Dante of our Psychiatric age,” by Errol Morris, and blogs about the DSM for the New Yorker. With The Book of Woe, written during and after his own participation in the revision process of the DSM-5, Greenberg doesn’t just paint the DSM as irrelevant, but as an arbitrary and totalitarian influence in the treatment of mental and emotional distress. Greenberg makes an unsparing case against the DSM’s hold on the naming rights to our psychic suffering.

What is the most disturbing aspect of the DSM-5 to you?
The most disturbing aspect is not unique to the DSM-5, but intrinsic to any DSM: that a private guild—the American Psychiatric Association (APA)—owns such an important public trust. The DSM plays a significant role in determining who gets treatment, what drugs get approved, what research gets funded, who gets special education services, and the disposition of criminal cases. The APA represents only one of many mental health professions, is rife with conflicts of interest with the pharmaceutical industry, has its own, scientifically questionable approach to treatment, it also stands to make hundreds of millions of dollars from the manual and associated products. That’s unseemly. But even worse, it leaves the public at the mercy of people who are not accountable to anyone except their own organization. It’s the worst kind of privatization.

What effect do you see the DSM-5 having on treatment for drug and alcohol addiction?
I’m not sure the DSM-5 will have any direct effect on treatment; the DSM-5 is not a treatment manual. But any DSM has a major indirect effect on treatment: It provides the diagnoses that are the tickets to treatment resources. To put it more concisely: money. The DSM-5 will most likely eliminate the categories of Substance Abuse and Substance Dependence in favor of a new super-category of Substance Use Disorder. Qualifying for this diagnosis may be easier than for the DSM-IV diagnoses, largely because the number of criteria a patient has to meet has been reduced. Some studies indicate that this will result in a large increase in prevalence. If General Motors comes out with a new car, that doesn’t change the number of drivers, and if the APA comes out with a new diagnosis, that doesn’t change the number of people who will qualify for a mental disorder diagnosis. Whether this happens, and if it does, whether it’s a bad thing (treatment resources are overburdened by an influx of new patients) or a good thing (more people get treatment), or whether it will have any effect at all, remains to be seen.

You say that psychiatry should not have a monopoly on the diagnoses and treatment of human suffering, such as addiction. Who else should be involved? Based on what “expertise” or “interests”?
Diagnosis and treatment are really two separate issues. I don’t think psychiatry claims to have a monopoly on treatment, although it does have (mostly) a monopoly among mental health providers on drug treatments. On this, I think I agree with the psychiatrists. I’m not sure that anyone else besides people who have been to medical school should be prescribing drugs. As for diagnosis, I don’t think psychiatric diagnosis is necessary, at least not until psychiatry has the knowledge to render diagnoses on the same basis as other medical specialties. Psychiatrists don’t treat mental disorders. They treat symptoms. So they don’t really need diagnoses to do their job. But if there has to be psychiatric diagnosis, then it should be in the hands of a public agency, one that doesn’t have a profit motive in fashioning a manual, one that is not wedded to its own professional interests, and one that is not fooling around with the drug industry.

“I tell my patients the truth: that if they want to use their insurance, I have to diagnose them with a mental disorder, and that this diagnosis will stay with them for the rest of their lives.”

Addiction is increasingly being recognized as a brain disease. One aim of the DSM-5 is said to be to bring diagnoses of substance use disorders into line with the burgeoning neuroscience about addiction. Does the DSM-5 meet its goal?
The only way in which DSM-5‘s addictive disorders section reflects neuroscience is in its reliance on “craving” as one of the two diagnostic criteria for substance use disorder. This change reflects the belief that craving is a single phenomenon with a particular brain chemistry. While there are some indications that this is the case, it is far from proven. 50 or 100 years from now, I am sure our understanding of the brain will seem as laughable as phrenology seems to us. So for the moment, popping people into PET scanners or MRI machines strikes me as wishful thinking multiplied by greed. The fact that addiction is increasingly being recognized as a brain disease does not mean that addiction is—or is best understood as—a brain disease. I don’t doubt that is the direction in which research is moving, but I’m not sure this means we are approaching the truth about addiction, or about the brain and its relationship to the mind.

What is your opinion on the effect of 12-step based programs on recovery—the spiritual solution rather than the medical?
I think the 12-step program is useful for many people, and I have both friends and patients who benefit from it. I also think it is only one of many ways that people can stop using the drugs they are addicted to, and is surely not the only “spiritual” approach. Nor is it necessarily correct to think of it in contradistinction to the medical approach. After all, the 12-step program owes much of its success to a concerted effort on the part of doctors, including psychiatrists, to popularize the disease model of addiction, which Alcoholics Anonymous in many respects originated.

The DSM-5 includes the first “behavioral disorder”—compulsive gambling—in the Addiction section. Proponents say that compulsive behaviors have very similar effects on the brain as substances do. Critics say this is opening the door to the medicalization of more and more of everyday life. What do you think?
I think that long before the behavioral disorders opened the door to medicalization of daily life, that goal had been accomplished. The struggle of psychiatry since 1980 has not been to fashion more and more illnesses, but rather to convince us that when we are unhappy, anxious, compulsive, etc., we have a mental illness. In this they have been successful, at least to judge from the vast increase in numbers of people seeking treatment. It’s a predictable outcome of the DSM approach to mental suffering.

Do you think 12-step culture might be overreaching with its own set of expanding diagnoses (shopping, varieties of sex addiction) or do you find them valid?
The idea that any compulsive behavior marked by craving is an addiction, and that addiction is a disease, is a very powerful one. It speaks to confusions deep in our culture about desire and satisfaction, about consumption and regret, about having and not-having. So I don’t think it’s fair to blame this tendency on 12-step culture. It’s obviously an idea whose time has come. But is it valid? Not if that means that sex addiction or Internet use disorder are diseases in the same way that cancer or diabetes are diseases. Addiction will remain poorly understood so long as we stay wedded to a strictly medical model (and I include in that the 12-step model, which, as I said, is also a disease model).

You write about the “magic bullet” effect of medication, an easy option for those addicts with a psychiatric diagnosis who could just do 12-step work.
I’m not sure it is useful to set up a polarity between “taking drugs” on the one hand and “doing the work” on the other. While drugs can be an “easy way out,” they are not always. Even Bill Wilson thought there was some value to LSD, and sometimes the absolute abstinence from all drugs, not just the drug to which a person has become addicted, that is required in some 12-step programs is counterproductive.

Some critics of the revision say that the expansion of diagnoses is a big boon for the drug industry, since there will be more people to medicate. Psychiatry is the darling of the drug industry. Do you believe that the DSM-5 was guided by this same self-interest?
Yes, of course. Psychiatry long ago hitched its wagon to the medical star, and increasingly that means to the neuroscience star. The failure of DSM-5 to develop a brain-based nosology is only the latest embarrassment that has resulted from this dogged determination to prove that psychiatry is just like the rest of medicine—real doctors treating real diseases. Too bad the profession has turned its’ back on what once made it unique and valuable: its focus on the mind.

As a psychotherapist, do you use the DSM-5?
In my practice, it has virtually no clinical value. Its primary value is its ability to help patients use their insurance to pay for therapy. I tend to discourage patients from doing this. I’d rather make less money than participate in a practice I don’t believe in. So I tell them the truth: that if they want to use their insurance, I have to diagnose them with a mental disorder, and that this diagnosis will stay with them for the rest of their lives. If they want to go ahead with it anyway, then we talk about the diagnosis I am going to use to make sure that they fully understand the implications of diagnosis, including the fact that DSM diagnoses are not real diseases, but rather constructs.

William Georgiades
William Georgiades is the executive editor of The Fix.

A weekly roundup of the best of Pacific Standard and PSmag.com, delivered straight to your inbox.

Recent Posts

December 20 • 10:28 AM

Flare-Ups

Are my emotions making me ill?


December 19 • 4:00 PM

How a Drug Policy Reform Organization Thinks of the Children

This valuable, newly updated resource for parents is based in the real world.


December 19 • 2:00 PM

Where Did the Ouija Board Come From?

It wasn’t just a toy.


December 19 • 12:00 PM

Social Scientists Can Do More to Eradicate Racial Oppression

Using our knowledge of social systems, all social scientists—black or white, race scholar or not—have an opportunity to challenge white privilege.


December 19 • 10:17 AM

How Scientists Contribute to Bad Science Reporting

By not taking university press officers and research press releases seriously, scientists are often complicit in the media falsehoods they so often deride.


December 19 • 10:00 AM

Pentecostalism in West Africa: A Boon or Barrier to Disease?

How has Ghana stayed Ebola-free despite being at high risk for infection? A look at their American-style Pentecostalism, a religion that threatens to do more harm than good.


December 19 • 8:00 AM

Don’t Text and Drive—Especially If You’re Old

A new study shows that texting while driving becomes even more dangerous with age.


December 19 • 6:12 AM

All That ‘Call of Duty’ With Your Friends Has Not Made You a More Violent Person

But all that solo Call of Duty has.


December 19 • 4:00 AM

Food for Thought: WIC Works

New research finds participation in the federal WIC program, which subsidizes healthy foods for young children, is linked with stronger cognitive development and higher test scores.


December 18 • 4:00 PM

How I Navigated Life as a Newly Sober Mom

Saying “no” to my kids was harder than saying “no” to alcohol. But for their sake and mine, I had to learn to put myself first sometimes.


December 18 • 2:00 PM

Women in Apocalyptic Fiction Shaving Their Armpits

Because our interest in realism apparently only goes so far.


December 18 • 12:00 PM

The Paradox of Choice, 10 Years Later

Paul Hiebert talks to psychologist Barry Schwartz about how modern trends—social media, FOMO, customer review sites—fit in with arguments he made a decade ago in his highly influential book, The Paradox of Choice: Why More Is Less.


December 18 • 10:00 AM

What It’s Like to Spend a Few Hours in the Church of Scientology

Wrestling with thetans, attempting to unlock a memory bank, and a personality test seemingly aimed at people with depression. This is Scientology’s “dissemination drill” for potential new members.


December 18 • 8:00 AM

Gendering #BlackLivesMatter: A Feminist Perspective

Black men are stereotyped as violent, while black women are rendered invisible. Here’s why the gendering of black lives matters.


December 18 • 7:06 AM

Apparently You Can Bring Your Religion to Work

New research says offices that encourage talk of religion actually make for happier workplaces.


December 18 • 6:00 AM

The Very Weak and Complicated Links Between Mental Illness and Gun Violence

Vanderbilt University’s Jonathan Metzl and Kenneth MacLeish address our anxieties and correct our assumptions.


December 18 • 4:00 AM

Should Movies Be Rated RD for Reckless Driving?

A new study finds a link between watching films featuring reckless driving and engaging in similar behavior years later.


December 17 • 4:00 PM

How to Run a Drug Dealing Network in Prison

People tend not to hear about the prison drug dealing operations that succeed. Substance.com asks a veteran of the game to explain his system.


December 17 • 2:00 PM

Gender Segregation of Toys Is on the Rise

Charting the use of “toys for boys” and “toys for girls” in American English.


December 17 • 12:41 PM

Why the College Football Playoff Is Terrible But Better Than Before

The sample size is still embarrassingly small, but at least there’s less room for the availability cascade.


December 17 • 11:06 AM

Canadian Kids Have a Serious Smoking Problem

Bootleg cigarette sales could be leading Canadian teens to more serious drugs, a recent study finds.


December 17 • 10:37 AM

A Public Lynching in Sproul Plaza

When photographs of lynching victims showed up on a hallowed site of democracy in action, a provocation was issued—but to whom, by whom, and why?


December 17 • 8:00 AM

What Was the Job?

This was the year the job broke, the year we accepted a re-interpretation of its fundamental bargain and bought in to the push to get us to all work for ourselves rather than each other.


December 17 • 6:00 AM

White Kids Will Be Kids

Even the “good” kids—bound for college, upwardly mobile—sometimes break the law. The difference? They don’t have much to fear. A professor of race and social movements reflects on her teenage years and faces some uncomfortable realities.



Follow us


Don’t Text and Drive—Especially If You’re Old

A new study shows that texting while driving becomes even more dangerous with age.

Apparently You Can Bring Your Religion to Work

New research says offices that encourage talk of religion actually make for happier workplaces.

Canadian Kids Have a Serious Smoking Problem

Bootleg cigarette sales could be leading Canadian teens to more serious drugs, a recent study finds.

The Hidden Psychology of the Home Ref

That old myth of home field bias isn’t a myth at all; it’s a statistical fact.

The Big One

One in two United States senators and two in five House members who left office between 1998 and 2004 became lobbyists. November/December 2014

Copyright © 2014 by Pacific Standard and The Miller-McCune Center for Research, Media, and Public Policy. All Rights Reserved.