Inside Psychiatry’s Battle to Define Mental Illness

March 15, 2011

AHRP – The authoritative expert who chaired the DSM-IV revision has become a formidable critic whose publicly expressed views about psychiatry’s diagnostic assessments and prescribed treatments–mostly chemical interventions–validate the criticism expressed by the Alliance for Human Research Protection for more than a dozen years.

by Vera Hassner Sharav
Alliance for Human Research Protection

In our era, psychiatry as a profession has suffered a significant loss of credibility: the most influential psychiatric leaders and academics have been shown to be agents for the drug industry, disregarding psychotropic drugs’ documented, severe, debilitating harmful effects for patients. The American Psychiatric Association itself acknowledged — under pressure from Senator Charles Grassley’s requests for APA’s funding sources — that over one third of its funding came from the drug industry.
 
Dr. Allen Frances, MD, the subject of an illuminating interview and article by Gary Greenberg in WIRED, chaired the American Psychiatric Association’s (APA) DSM-IV Task Force in the early 1990s but has recently become a formidable critic of APA’s revision process toward the DSM-5. His publicly expressed criticism of psychiatry’s grandiose ambition–demonstrated by its ever expanding list of unvalidated disease designations and reliance on demonstrably harm-producing chemical interventions–essentially validates the criticism expressed by the Alliance for Human Research Protection for more than a dozen years.
 
Greenberg’s article provides insight into the current raging battle generated by the APA’s draft proposals for the DSM-5. Everyone now knows that the DSM is often referred to as psychiatry’s “Bible,” as it determines how “mental illnesses” or “mental disorders” are to be defined, what behaviors are believed to require treatment, what mental health researchers can legitimately ask public funding to study, and — most importantly for all mental health practitioners — for what diagnoses insurance companies and government third-party payers are expected to reimburse or subsidize the costs of treatments that patients receive.
 
In a series of short opinion pieces and editorials, as in Greenberg’s interview, Dr. Frances now acknowledges:

“We made mistakes [in the DSM-IV] that had terrible consequences. … Diagnoses of autism, attention-deficit hyperactivity disorder, and bipolar disorder skyrocketed,” and he indicates that his manual inadvertently facilitated these epidemics—and, in the bargain, fostered an increasing tendency to chalk up life’s difficulties to mental illness and then treat them with psychiatric drugs.”

Greenberg notes:

“What the battle over DSM-5 should make clear to all of us—professional and layman alike—is that psychiatric diagnosis will probably always be laden with uncertainty, that the labels doctors give us for our suffering will forever be at least as much the product of negotiations around a conference table as investigations at a lab bench.”

Indeed, even APA’s research chief, Darrel Regier, and APA’s medical director, James Scully are now more than willing to acknowledge this uncertainty. Scully says: “The DSM will always be provisional; that’s the best we can do.”  And Regier states: “The DSM is not biblical. It’s not on stone tablets.”
 
But, as Greenberg notes, “The real problem is that insurers, juries, and (yes) patients aren’t ready to accept this fact. Nor are psychiatrists ready to lose the authority they derive from seeming to possess scientific certainty about the diseases they treat. After all, the DSM didn’t save the profession, and become a best seller in the bargain, by claiming to be only provisional.”
 
To critics, Greenberg writes, the greatest liability of the DSM-5 process is precisely this disconnect between its ambition on one hand and the current state of the science and the practice of classifying emotional distress and misbehaviors on the other. Of particular concern is a proposal to institute “dimensional assessment” as part of all diagnostic evaluations. In this approach, clinicians would assign a severity rating to each patient’s illness, rather than merely decide, according to the current “categorical” assessment, whether a person “has” or “does not have” a mental disorder.
 
As we, the Alliance for Human Research Protection, have persistently noted, the DSM battles (including those leading to DSM-III, DSM-III-R, DSM-IV, and now, DSM-5) have been about how the APA, dominated as it is by the pharmaceutical industry’s goals to market as many psychotropic drugs to as many living human beings as possible, has invented and promoted diagnostic categories as the names of objective diseases without any solid way to validate them.
 
In the absence of scientific evidence, the current DSM-5 Task Force has embarked on broad revisions that are bound to encourage “early intervention” even for asymptomatic, undefined, but named “conditions.” These include “Psychosis Risk Syndrome” — later repackaged as “Attenuated Psychotic Symptoms Syndrome” — and “Minor Neurocognitive Disorder.”
 
It is hard to imagine a greater service rendered to the drug industry than expanding the classification of mental conditions to include even symptom-free individuals in the APA’s DSM-5! “Early intervention” will predictably multiply the number of Americans diagnosed and treated for arbitrarily defined “mental illness.” Naturally, this has caused some friction within the Task Force.
 
The APA refuses to wait for evidence that would determine the validity of diagnoses and early drug interventions, even as evidence abounds from the federally-funded CATIE, STAR*D, and STEP-BD studies that drug interventions fail more often than they succeed for the treatments of conditions with long-established diagnoses. Surely, this quantum leap is propelled by financial conflicts of interest.
 
E. Jane Costello, co-director of the Center for Developmental Epidemiology at Duke Medical School, was one of two psychiatrists who resigned from the DSM-5 Childhood Disorders work group in spring 2009. In her resignation letter, which she subsequently made public, Costello excoriated the DSM committee for refusing to wait for the results of longitudinal studies she was planning and for failing to underwrite adequate research of its own. The proposed revisions, she wrote, “seem to have little basis in new scientific findings or organized clinical or epidemiological studies.” (In a response, the APA cited “several billions of dollars” already spent over the past 40 years on research the revision is drawing upon.)
 
The problem is that in more than 30 years of research guided by the DSM-III approach, psychiatry has failed to develop a single valid objective diagnostic tool, or to provide insight into the pathophysiology of mental illness, or to justify psychiatry’s near-complete reliance on increasingly toxic chemical interventions. Even Carol Bernstein , the current president of the APA, acknowledges in this month’s Psychiatric News the absence of any validated diagnostic tools in psychiatry: 

“It became necessary in the 1970s to facilitate diagnostic agreement among clinicians, scientists, and regulatory authorities given the need to match patients with newly emerging pharmacologic treatments and the associated need to conduct replicable clinical trials so that additional treatments could be approved. While it is true that no system based entirely on clinical description can match the levels of diagnostic agreement made possible by objective medical tests, there were no good alternatives for psychiatry when DSM-III was published in 1980. Indeed, even today objective tests and biomarkers for mental disorders remain research goals rather than clinical tools.”

Allen Frances, the Chair of the Task Force that authored the diagnostic concepts in the DSM-IV, psychiatry’s diagnostic “Bible,” now confesses that “these concepts are virtually impossible to define precisely with bright lines at the boundaries.”

APA president, Carol Bernstein, echoes that damning criticism:

“Despite substantial progress in producing interrater reliability, it was widely recognized that it was premature to consider DSM-III diagnoses as representing etiologically determined diagnoses. This contrasts to the situation in scientifically more mature (some would say less difficult) areas of medicine where diseases are identified by more “objectively” ascertainable abnormalities of anatomy, physiology, or biochemistry and where genetic and environmental etiologies are increasingly certain.” (Below, Bernstein’s own damning indictment of the DSM approach).

This acknowledgment by psychiatry’s most authoritative expert on diagnosis confirms what critics have been saying all along; namely, that the DSM definitions of mental disorders are speculative and arbitrary, lacking the legitimacy of science. 

The DSM-5 revision process mirrors the disconnect between psychiatry’s grandiose ambition and the absence of scientific legitimacy to support its diagnostic or clinical practices.

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