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PSYCHIATRY'S EARLY BREAKDOWN AND THE RISE OF THE DSM
On a chilly Wednesday morning in late January, I pass through the gates of my university after a fraught drive through London's rush hour traffic. With two minutes left on the clock, I make my way hurriedly to the ground floor of the lecture theater. Today I am expected to deliver my first lecture on critical psychiatry.
As I enter the room it feels more close and cramped than usual, as nearly every student on the course has decided to attend (which, I must add, doesn't always happen on cold January mornings). The students are busily preoccupied as I approach the lectern and start quietly ordering my notes. Many of the students are chatting intently, some are tapping on laptops or mobiles, while a few eager souls (in the front row, of course) quietly sit waiting for me to begin.
"Right, everyone, settle down," I say firmly to halt the chatter. "I have a great piece of research I want you to consider. You'll like this one, trust me, so please listen closely." I clear my throat and begin.
"Some years ago during a balmy April, a group of seven academics conducted a dramatic experiment, months in preparation. As part of the experiment, they individually presented themselves at different psychiatric hospitals dotted around the United States. Each academic then told the psychiatrist on duty that they were hearing a voice in their head that said the word 'thud'. That was the only lie they should tell; otherwise, from that point on they should behave and respond completely normally. All of them were admitted into their respective hospitals. And all were diagnosed with schizophrenia and given powerful antipsychotic pills. All the while they acted completely normally.
"The experimenters thought they would be in for a couple of days and then be discharged, but they were wrong. Most were held for weeks, and some for in excess of two months. They could not convince the doctors they were sane. And telling the doctors about the experiment only compounded the problem. So it quickly became clear that the only way out was to agree that they were insane, and then pretend to be getting better.
"Once the leader of the experiment, Dr. David Rosenhan, got out and reported what had happened, there was an uproar in the psychiatric establishment. Rosenhan and his colleagues were accused of deceit. One major hospital challenged Rosenhan to send some more fake patients to them, guaranteeing that they would spot them this time. Rosenhan agreed, and after a month the hospital proudly announced to the national media that they had discovered forty-one fakes. Rosenhan then revealed that he had sent no one to the hospital at all."
For a moment there is stunned silence in the lecture room, quickly followed by some chuckling and surprised chatter. I now have their full attention. Three or four hands shoot up.
"Hold your questions for now, everyone," I say calmly. "I've another series of experiments to tell you about first. These occurred around the same time as Rosenhan's experiment, and were as equally devastating for psychiatry.
"These experiments explored the following question," I continued. "Would two different psychiatrists diagnose the same patient in the same way? To answer this, the researchers presented the same set of patients to different psychiatrists, in different places, to see whether their diagnoses would match up. When the results came in, the situation did not look good.
"Taken en masse, the results revealed that two psychiatrists would give different diagnoses to the same patient between 32 percent and 42 percent of the time. And this troubling result was confirmed by another series of studies, which showed that psychiatrists in the United States and in Russia were twice as likely to diagnose their patients as schizophrenic than their colleagues in Britain and Europe. This meant that the diagnosis you could be assigned not only often depended on who your psychiatrist was, but on where your psychiatrist was located. How could you therefore trust your diagnosis, when a different psychiatrist was likely to diagnose you with something else?"
I told my students about these experiments because in the history of psychiatry, they were considered game-changers. They plunged psychiatry into severe crisis in the 1970s by exposing that there was something terribly wrong with the diagnostic system. Psychiatrists were not only defining sane people as insane, but when two psychiatrists at any given time were faced with the same patient, they would assign different diagnoses nearly half the time. So why were these critical mistakes being made?
The profession was desperate for an answer. And when one finally emerged in the 1970s, the course of psychiatry would be altered for good. There was a serious problem with the centerpiece of the entire profession—the psychiatrist's bible: the DSM.
So what, you may ask, is the DSM? To answer this question, please follow me into the office of Dr. Herbert Pardes, one of America's leading psychiatrists. To give you some idea of his professional standing, just consider his resumé. He was former chair of Columbia University's Department of Psychiatry (the most powerful psychiatry department on the globe), former president of the American Psychiatric Association (the more glitzy US equivalent of the Royal College of Psychiatrists), and finally, former director of the largest psychiatric research organization internationally (The National Institute for Mental Health). In short, if there were a CEO of psychiatry, then Herbert Pardes was probably it.
Pardes welcomed me into his office with an easy smile and a warm handshake. "I'm glad we've finally managed to make this meeting happen," said Pardes kindly. "Come on over, take a seat."
As I crossed the office, I was immediately surprised by its unexpected grandeur. There was an elegant dining area at the room's center, a suite of recherché sofas off to one side, two walls capaciously lined with sleek bookshelves and another with fine contemporary art, a huge, flat-screen TV mounted in one corner, a large writing desk in another, and a copious window spanning sixty-five feet, with spectacular views over the Hudson River. In real estate terms, if this were an apartment, only a handful of people could probably ever afford it. So this, it now appeared, was what the pinnacle of psychiatry looked like.
Once Pardes and I had settled comfortably into two chairs, the first topic I pressed him on was the DSM. "If you don't understand the history of the DSM," insisted Pardes, "you cannot hope to understand modern psychiatry." The DSM is shorthand for the Diagnostic and Statistical Manual of Mental Disorders, and is the book that lists all the psychiatric disorders that psychiatrists believe to exist. "So the DSM contains every mental disorder with which you or I could be potentially diagnosed," said Pardes, "and that's its significance."
Pardes then briefly recalled the DSM's journey from its modest 130 pages in 1952 to the 886 pages it boasts today. In short, he emphasized that the first edition of the DSM was written in order to solve a problem that had plagued the profession for decades. Until the 1950s, psychiatrists working in different places possessed no shared dictionary of mental disorders in which all the disorders were clearly defined and which carefully listed each disorder's core symptoms. Without this dictionary, the behavior that one psychiatrist called "melancholic" or "depressive," another psychiatrist was likely to call something else. So this made communication between psychiatrists in different places almost impossible.
"If I say to another psychiatrist that I have tried the drug Thorazine on 250 people with paranoid schizophrenia," explained Pardes, "what happens if this other psychiatrist's definition of paranoid schizophrenia is not the same as mine? Our discussion becomes meaningless. So the DSM was developed," continued Pardes, "to try to identify and standardize the symptoms characteristic of any given mental illness—anxiety disorder, phobia, mood disorder, and so on." Every psychiatrist was then expected to learn this list so that different psychiatrists in different places would all be working from the same page.
Once the first DSM arrived in the 1950s, psychiatrists were then expected to use the dictionary in the same standardized way still in operation today. For instance, if you go and visit a psychiatrist tomorrow because you are feeling down, the psychiatrist will ask you to describe your symptoms. The purpose of this is to try and work out from your symptoms what diagnosis from the diagnostic dictionary you should be assigned.
For example, if you report feeling tense, irritable, and panicky, and that you have been feeling this way for over two weeks, then you are likely to be diagnosed with one of the anxiety disorders. Whereas if you mention you are feeling sad, teary, lethargic, and are experiencing disrupted sleep, then you are more likely to be diagnosed with one of the depressive disorders. Of course, sometimes your symptoms will not fall neatly into any single category, but rather span two or three. In this case your problem will be considered "comorbid"—namely, that you are suffering from a disorder that is occurring simultaneously with another (e.g., perhaps you suffer from major depression as well as panic disorder). But whether your condition is comorbid or not, the diagnostic process is the same: your psychiatrist attempts to match your symptoms as closely as possible to one of the diagnostic labels listed in the book.
Now here comes the problem—and it is a problem that still afflicts psychiatry today. How does your psychiatrist know if he or she has assigned the correct diagnosis? Is there a safe and reliable way that he or she can test, objectively speaking, whether the diagnosis given is the right one? I put this question to Pardes.
"Well, one way to test whether the diagnosis is correct is to apply a scientific or biological test [such as a blood, urine, saliva test, or some other form of physical examination to assess, firstly, whether a patient has a mental disorder, and if so, precisely what disorder they suffer from]. But the crucial problem for psychiatry is that we still have no such objective biological tests."
In other words, unlike in other areas of medicine where a doctor can conduct a blood or urine test to determine whether he has reached the correct diagnosis, in psychiatry no such methods exist. And they don't exist, as Pardes also intimated, because psychiatry has yet to identify any clear biological causes for most of the disorders in the DSM (this is a pivotal point, which I'll talk about more fully in coming chapters). So the only method available to psychiatrists is what we could call the "matching method": match the symptoms the patient reports to the relevant diagnosis in the book.
Although at first glance they may appear innocuous, these facts are crucial for understanding why psychiatry in the 1970s fell into serious crisis. They help us explain why psychiatrists were not only guilty of branding sane people as insane (e.g., as the Rosenhan experiment revealed) but also guilty of regularly failing to agree on what diagnosis to assign a given patient (e.g., as the "diagnostic reliability" experiments showed). Psychiatry was making these errors because it possessed no objective way of testing whether a given person was mentally disordered, and if so, precisely what disorder he or she was suffering from. Without such objective tests, the diagnosis a psychiatrist would assign could be influenced by his subjective preferences, and as different psychiatrists were swayed by different subjective factors, it was understandable that they regularly disagreed about what diagnosis to give.
This is why these early experiments were so dramatic for the profession: they produced for the first time clear evidence that psychiatric diagnosis was at best imprecise and at worst a kind of professional guesswork. And so, without any objective way of testing the validity of a diagnosis, psychiatry was in peril of falling far behind the diagnostic achievements of other branches of medicine.
A solution was needed ... and fast.
Under the leadership of the American Psychiatric Association (APA), the profession in the 1970s plumbed for a radical solution. It decided to tear up the existing edition of the DSM (then called DSM-II) and literally start again. The bold idea was to write an entirely new manual that would solve all the problems beleaguering DSM-II. This new manual would be called DSM-III, and its central aim would be to improve the reliability of psychiatric diagnosis and thereby answer the mounting criticisms that were threatening to shatter the profession's legitimacy.
The first step the APA took was to set about finding someone to lead the writing of the DSM-III. The APA needed a person highly competent, energetic, and daring, but also someone who had experience with psychiatric classification. After sifting through countless candidates and enduring many frustrations, the APA finally settled on a man called Dr. Robert Spitzer, who was based at Columbia University's medical school.
Spitzer had been a young, up-and-coming psychiatrist when the earlier DSM-II had been written, and he had also been minimally involved in that project. But most important, he appeared to have the drive and vigor needed to get the job done. As the APA was sufficiently impressed with his qualities, they hired him in 1974 to start work on the new DSM-III. Little did Spitzer know at the time that his appointment as chair of DSM-III would ultimately make him the most influential psychiatrist of the twentieth century.
The first thing Spitzer did to reform the DSM was to assemble a team of fifteen psychiatrists to help him write the new manual. This team was called the DSM Taskforce, and Spitzer was its outright leader. So in the mid-1970s, the taskforce set about writing a kind of New Testament, if you will, for psychiatry: a book that aspired to improve the uniformity and reliability of psychiatric diagnosis in the wake of all its previous failings. If this all sounds very intrepid, that's pretty much what it was. Spitzer's taskforce promised a new deal for psychiatry, and there was a lot of pressure on it to deliver.
So what precisely did Spitzer do to try and set things right? How was he going to make psychiatric diagnosis more reliable and scientific? His answer was simple. The DSM needed to be altered in three major ways:
Many existing disorders would be deleted from DSM-II.
The definitions of each disorder in the old DSM would be expanded and made more specific for DSM-III.
A new checklist would be developed for DSM-III to improve the reliability of diagnosis.
Let's briefly look at each of these alterations more closely. The first involved Spitzer deleting some of the more unpopular and controversial mental disorders. These included some of the disorders introduced into psychiatry by psychoanalysis. In the 1970s, psychoanalysis had fallen out of vogue in psychiatry, along with many disorders it had introduced to the previous DSM. One of the most controversial of these disorders was homosexuality. Indeed, in the DSM-II homosexuality was listed as a mental disease. It was described as a "sexual deviation" and was located in the same category as pedophilia.
While some psychiatrists felt it was wrong to brand homosexuality an illness, the main push to remove the disorder largely came from outside pressure groups including the Gay Rights Movement. These groups asked why a normal and natural human sexual preference had been included in the DSM as a mental disease, especially when there was absolutely no scientific evidence to justify its inclusion. Surely it was prejudice rather than science that had placed homosexuality on the list?
Many in the psychiatric community were not so sure, but the APA, perhaps sensing the change in public mood, decided to consult the wider psychiatric community for their views. So at the APA convention in 1973, all the attending members were asked to vote on what they believed: was homosexuality a mental disorder or not? The vote was closer than expected: 5,854 psychiatrists voted to take homosexuality out of the DSM, while 3,810 voted to keep it in. And because the "outers" were in the majority, homosexuality ceased to be a mental disorder in 1974 and was therefore not included in Spitzer's DSM-III. It was politics and not science that had removed the disorder from this list. As we continue, it is worth holding that thought in mind.
Excerpted from Cracked by James Davies. Copyright © 2013 James Davies. Excerpted by permission of PEGASUS BOOKS.
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