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Wrangling over psychiatry's bible
Over the summer, a wrangle between eminent psychiatrists that had been brewing for months erupted in print. Startled readers of Psychiatric News saw the spectacle unfold in the journal's normally less-dramatic pages. The bone of contention: whether the next revision of America's psychiatric bible, the "Diagnostic and Statistical Manual of Mental Disorders," should be done openly and transparently so mental health professionals and the public could follow along, or whether the debates should be held in secret.
One of the psychiatrists (former editor Robert Spitzer) wanted transparency; several others, including the president of the American Psychiatric Assn. and the man charged with overseeing the revisions (Darrel Regier), held out for secrecy. Hanging in the balance is whether, four years from now, a set of questionable behaviors with names such as "Apathy Disorder," "Parental Alienation Syndrome," "Premenstrual Dysphoric Disorder," "Compulsive Buying Disorder," "Internet Addiction" and "Relational Disorder" will be considered full-fledged psychiatric illnesses.
This may sound like an arcane, insignificant spat about nomenclature. But the manual is in fact terribly important, and the debates taking place have far-reaching consequences. Published by the American Psychiatric Assn. (and better known as the DSM), the manual is meant to cover every mental health disorder that affects children and adults.
Not only do mental health professionals use it routinely when treating patients, but the DSM is also a bible of sorts for insurance companies deciding what disorders to cover, as well as for clinicians, courts, prisons, pharmaceutical companies and agencies that regulate drugs. Because large numbers of countries, including the United States, treat the DSM as gospel, it's no exaggeration to say that minor changes and additions have powerful ripple effects on mental health diagnoses around the world.
Behind the dispute about transparency is the question of whether the vague, open-ended terms being discussed even come close to describing real psychiatric disorders. To large numbers of experts, apathy, compulsive shopping and parental alienation are symptoms of psychological conflict rather than full-scale mental illnesses in their own right. Also, because so many participants in the process of defining new disorders have ties to pharmaceutical companies, some critics argue that the addition of new disorders to the manual is little more than a pretext for prescribing profitable drugs.
The more you know about how psychiatrists defined dozens of disorders in the recent past, the more you can appreciate Spitzer's concern that the process should not be done in private. Although a new disorder is supposed to meet a host of criteria before being accepted into the manual, one consultant to the manual's third edition -- they're now working on the fifth -- explained to the New Yorker magazine that editorial meetings over the changes were often chaotic. "There was very little systematic research," he said, "and much of the research that existed was really a hodgepodge -- scattered, inconsistent and ambiguous. I think the majority of us recognized that the amount of good, solid science upon which we were making our decisions was pretty modest."
Things are different today, the new consultants insist, because hard science now drives their debates. Maybe so, but still, I shudder to think what the criteria for "Relational Disorder" and "Parental Alienation Syndrome" will be. And I'm not the only one worrying. Spitzer is bothered by the prospect of "science by committee." Others, like forensics expert Karen Franklin, writing in American Chronicle, warn that advocacy groups are pressing for the inclusion of dubious terms that simply don't belong in a manual of mental illnesses.
The row between Spitzer and Regier apparently dates to Regier's refusal to share the minutes of his task-force meetings with Spitzer, citing concerns about confidentiality that could jeopardize the integrity of the discussions. Regier insists, in personal correspondence that has since been made public, that the process is designed to ensure "input" from all interested parties. But Regier won't share any information except a handful of "periodic reports to the membership and media." Bypassed, conveniently, are the details of the debates themselves.
Spitzer counters that "the real purpose ... is to avoid possible criticism of the ... process." He has called the attempt to revise the DSM in secret "a big mistake" and a likely "public relations disaster."
I fear that I may have unintentionally contributed to Regier's excessively secretive behavior. Back in the 1970s, during the creation of the third edition of the manual, I published much of the correspondence that had circulated between committee members. Some of the exchanges were frankly hair-raising. They included proposals for the approval of such dubious conditions as "Chronic Complaint Disorder" and "Chronic Undifferentiated Unhappiness Disorder." When asked to define how he was using the term "masochism," one leading psychiatrist replied: "Oh, you know what I mean, a whiny individual ... the Jewish-mother type." And so it went for dozens of other terms that later became bona-fide illnesses.
Regier obviously wants to prevent any such embarrassment for his task force; he apparently fears the public will not find his committee's work entirely convincing.
I'm not interested in embarrassing anyone. My concern is the lack of proper oversight. If the proposed new disorders don't receive a full professional airing, including a vigorous debate about their validity, they will be incorporated wholesale into the fifth edition in 2012. Joining the ranks of the mentally ill will be the apathetic, shopaholics, the virtually obsessed and alienated parents. It's hard to imagine that anyone will be left who is not eligible for a diagnosis.
Christopher Lane, a professor of English at Northwestern University, is the author of "Shyness: How Normal Behavior Became a Sickness."