Proposed Psychiatry Changes Drawing Fire : Addition of Three New Diagnostic Categories Will ‘Stigmatize’ Women, Psychologists Fear

Charging sexism, elitism and exclusionary practices on the part of psychiatrists, a group of psychologists attending the 94th annual convention of the American Psychological Assn. last week launched a major attack on three categories proposed for inclusion in the American Psychiatric Assn.’s Diagnostic and Statistical Manual (DSM), viewed widely as the bible of mental health diagnosis.

The protest over ethical and legal ramifications of categories for periluteal phase dysphoric disorder, self-defeating personality disorder and sadistic personality disorder was echoed by the Psychological Assn.’s council of representatives. In a resolution adopted in the final hours of the five-day conference, the council called the diagnoses “without . . . any scientific basis” and “potentially dangerous to women” and urged that the three categories be omitted from the Psychiatric Assn.’s DSM-IIIR, an interim revision, scheduled for publication in early 1987.

Used by Courts, Firms

After several revisions, the Psychiatric Assn. has tentatively decided to include the three categories in the appendix of the newest edition of the manual first drafted to establish classifications of mental illness in 1952. The widespread use of the manual by insurance companies, the courts and state and national policy makers is in large part what has prompted fears on the part of some psychologists that the new terminology will “stigmatize” women, possibly serving as a barrier to employment or public service.

“The fact is,” said Renee Garfinkel, director of the Psychological Assn.’s women’s program office, “words, names and labels are very powerful.”

The new categorization “reinforces stereotypes,” said psychologist Sheryle Alagna of the Uniformed Services University of the Health Science in Bethesda, Md. “Clinically, it could be misused, obscuring significant contributions of the social context.”

“If you wonder how many people believe these words and labels,” said Laura Brown, a clinical and forensic psychologist in practice in Seattle, “think about how many of the notions that come from psychiatric thinking that we take for granted: the Freudian slip, the interpretation of dreams. The theories and notions of our profession have moved into the general culture and vocabulary.”

Said Brown: “These things creep down into the culture.”

In Philadelphia, psychiatrist Dr. Paul Fink, chairman of the ad hoc committee to review the DSM-IIIR, had this response to the debate: “The argument now is on a hysterical level. It’s not rational. If you read it (DSM-IIIR) through, those categories do not represent an anti-woman bias, and in my opinion they don’t have the potential for abuse.”

At the American Psychiatric Assn., public affairs director John Blamphin was of a similar mind: “We think there is a lot of feminist extremism in the reaction of a small group. We feel we have resolved the issues.”

200 Changes Proposed

The controversy surfaced late last year, when more than 200 changes and clarifications were proposed for the updated psychiatric diagnostic manual. “Amongst the 200 proposals,” Blamphin said, “there were maybe 20 that were controversial, including the three the psychologists referred to.” After additional reworking, most of the controversies were ironed out, Blamphin said, leaving about five or six.

One argument was over masochistic personality disorder. After still more review and field studies, the committee of psychiatrists agreed to retitle this category self-defeating personality disorder. While clinical and forensic psychologist Lenore E. Walker of Denver, for one, blasted that category as anti-female, saying it “blames the victim, not the perpetrator” of violence against women in particular, psychiatrist Fink was firm in saying that, “This is not a female illness.”

Fink, vice president of the Psychiatric Assn. and chairman of psychiatry at Albert Einstein Medical Center in Philadelphia, said, “We make it very clear that anyone who has been abused cannot be given this label. The abused people are excluded.”

One study--”not perfect,” Fink said--”showed that 35% of the people so labeled were men, and 65% were women. Most of the patients in my personal practice who have self-defeating personality disorder are men.

“Because of the pressure, we changed the term so it would not be confused with early psychiatric ideas that all women were born masochists.”

Protest Spreads

But critics were unconvinced. Joining in the protest, the 100,000-member National Assn. of Social Workers issued a statement declaring, “We feel that the diagnostic criteria for the self-defeating personality disorder describe what social workers know to be the transient effects of battering or sexual assault on women’s functioning. Describing it as a personality disorder implies grave and unchangeable psychopathology and it could be used against women in custody battles, self-defense murder cases and sexual harassment litigation.”

Another of the debated categories, premenstrual dysphoric disorder, was changed to periluteal phase dysphoric disorder, referring to a phase in the ovarian cycle. “The (original) name was unfortunate,” Blamphin said, “because people immediately confused it with premenstrual syndrome, or premenstrual tension, whatever you call it.” He called the current phrasing “one step removed from premenstrual.”

While many women report experiencing varying degrees of premenstrual tension or distress, “a small percentage of women, maybe 10%,” could be described as having premenstrual dysphoric disorder, Blamphin said. In severe cases, he said, “the disorder can mimic one of the psychoses.”

“There was this terrible feeling that we were making premenstrual tension a psychiatric disorder,” Fink said. “We were not.”

But from the psychologists’ perspective, Alagna said she was critical of the category for “indirectly establishing a gender-specific mental disorder.” Stressing that “both supporters and opponents of the diagnosis agree that there is a great variability of symptoms,” Alagna said the new labeling “targets women’s biology,” and poses the threat that “research guided by this diagnosis may be guided away from situational” explanations for certain disorders.

Alagna faulted information used by the psychiatrists in establishing this category, saying hard data was particularly difficult to come by for this condition. In one study she referred to, “just knowing that you were participating in a premenstrual syndrome study increased symptomatology by 80%.”

Said Alagna, “It is most surprising and disturbing that this diagnosis was even proposed at this time, much less accepted.”

‘Scientific Excuse’

Warned the social workers association, “The potential for this diagnosis to be used against women particularly as a so-called ‘scientific excuse’ for job discrimination is enormous.”

Along with the self-defeating personality disorder and periluteal phase dysphoric disorder categories, the Psychiatric Assn. also decided at a June meeting on the DSM-IIIR to place its sadistic personality disorder category in the appendix.

“We are not yet convinced that the scientific evidence, while impressive, is sufficiently strong to warrant inclusion in the text of the manual at this time,” American Psychiatric Assn. President Dr. Robert Pasnau said of the three contested subjects.

“But,” Pasnau said, “these disorders are of sufficient clinical importance to justify publishing them in the appendix to the manual for research and educational purposes.”

Listing the three categories in the appendix was in no way a compromise, psychiatrist Fink said, “just a realistic assessment of the situation.”

But placing the categories in the appendix was “an excuse to get them in the book,” psychologist Lynne Bravo Rosewater of Beachwood, Ohio, asserted. “It’s like sneaking them in the back door.”

After extensive discussion by the psychiatrists preparing the new manual, two other debated categories, ego-dystonic homosexuality, and paraphilic coercive disorder, were deleted. The former grouping refers to “homosexuals who persistently desire to establish heterosexual relationships but can’t because they are primarily aroused homosexually,” the Psychiatric Assn. said, “and is seldom used.”

Paraphilic coercive disorder “applies primarily to men who are driven by sexual fantasy to rape.” Calling the condition “relatively rare,” the Psychiatric Assn. said the category was withdrawn “because of the preliminary nature of the data and the difficulty physicians have in differentiating (this condition) from other disorders.”

“More than 25 advisory committees” involving more than 230 expert consultants worked on the revisions for the DSM-IIIR, the Psychiatric Assn. said.

More than 370,000 copies of the previous edition of the manual, have been sold worldwide.

‘Politics of Diagnostics’

But for psychologist Garfinkel, among others, the argument boiled down to one of “the politics of diagnostics.”

Said Garfinkel: “Politically controlled and economically conducted, the process serves neither the consumer nor the profession.”

Asked if the dispute might reflect some degree of intraprofessional rivalry, Garfinkel feigned innocent disbelief.

“Who,” she said, “us?”

Quick to squelch such questions, psychologist Brown said, “There are a number of psychiatrists who have expressed the same reservations.”

So concerned are the psychologists about possible misuses that may stem from the DSM-IIIR that they have agreed to publish their own diagnostic manual. No publication date has been set.

“This is a historic first,” psychologist Walker said. “We have talked about doing this for many years, but we have never felt shut out of the process as we have been during this time.”

“Their own system is increasingly outmoded and increasingly non-communicative to the larger aspects of society,” clinical psychologist Hannah Lerman of Los Angeles said.

But in Philadelphia, psychiatrist Fink called the whole situation “a tremendous tempest in a teapot.

“We have really tried to maneuver it so that they (the psychologists) feel that they got something. And because we didn’t take out every one of these diagnostic categories, they feel defeated. Now to me, that’s not reasonable.”

“This is very important,” psychologist Garfinkel said. “It affects every person who sees any mental health professional.”