Pity the poor American Psychiatric Association, Part 1

You do have to feel a little sorry for the APA. AS John Boehner might say, they’ve been kicking a can down the road for thirty years now. And, not to mix cliches or anything, the chickens are finally coming home to roost.

Way back when, in 1980, the APA published its DSM-III to great acclaim. With its comprehensive listing of hundreds of mental disorders, one for nearly every human foible, the book formalized something that had been going on for years in American society: that we were increasingly turning our troubles over to mental health professionals. Each disorder had a list of criteria that, so the claim went, could be used by clinicians to arrive at diagnoses reliably, meaning that with any given patient, two clinicians were more likely than not to agree on a diagnosis.

This feature of the DSM–its increased reliability–was said by many to have saved American psychiatry, which had taken some serious blows to its credibility in the years leading up to DSM-III. The book reassured the public that psychiatrists knew what they were talking about when they said a person had depression or schizophrenia. It also seemed to guarantee that never again would psychiatry mistake mere deviance from social norms for psychopathology, as it had with homosexuality. Thanks to the DSMs lists, psychiatrists could now claim that, like other doctors, they knew the difference between illness and health, they knew what illnesses they were treating, and they knew those illnesses were real.

The DSM-III was a bestseller, as were its three subsequent revisions. No one really knows why, but really when you’re selling millions of copies of a book, you don’t really stop to ask. You just ring up the cash register.

But at least part of its appeal has to be its claim to be an authoritative compendium of the mental illnesses that exist in nature. This is a useful claim for, say, a lawyer trying to get his client off of a criminal charge on the grounds of mental illness, or for a researcher trying to get grant money to study a mental illness, or for a drug company trying to convince the Food and Drug Administration that its drug is a treatment for a mental illness. Juries, grants administrators, and drug regulators are all assured that the condition is question is a real illness. And so are insurance companies when they fork over the cash for mental health treatments.

But here’s a curious thing. The experts on the DSM, all of them, will tell you, if you ask, that in fact the disorders listed in the book are not real. They will say they are “fictive placeholders.” They will say they are “useful constructs.” They will say they are “our best guess” about what mental illnesses exist in nature. They will tell you that the notion that the disorders are real is a total misapprehension of what the book is really about. And most strikingly, they will tell you that psychiatrists, at least good psychiatrists, are not responsible for that misapprehension. “The DSM is a victim of its own success,” one DSM expert told me. It’s such a good book that people have “taken it too seriously,” and “reified” those constructs.

None of this would necessarily be a problem for the APA if they could continue to have it both ways–to gain authority from the DSM’s appearance even as they can insist that the reality is different. But there are, as Marx might have said, some internal contradictions here. Notably, the DSM doesn’t do such a good job of sorting people into their fictive placeholder categories. People often turn out to have two or three or four mental illnesses, which offends the sensibilities of scientists and laypeople everywhere. As does the fact that epidemiological studies, in which people in a community (as opposed to people who show up at doctors’ offices) are given various screening tests, show that something like 30 percent of us are or will be mntally ill at some point in our lives. And then there are the mental illness epidemics that sweep the land with regularity–childhood bipolar disorder, multiple personality disorder, social anxiety disorder, etc.–and the use of dangerous and sometimes untested drugs to treat these supposed illnesses. Within medicine and in the general public, psychiatry is in danger of once again falling into disrepute. Or, as one of its presidents put it in her farewell address, “Our enemies will use confusion about the DSM to undermine us.”

The DSM is currently under revision. The new DSM will be called the DSM-5. When it was conceived, more than a decade ago, this revision was going to address some of these problems. The obvious–at least to doctors–solution is to tie mental illnesses to their biological causes. You know, find out what’s going on in the brains of suffering people and classify them accordingly. You might think they’ve already done that, what with all the talk of chemical imbalances as the culprit in depression and other disorders, but in fact they haven’t. They haven’t even come close. And they aren’t about to, at least not in time for the DSM-5, which the APA has decided must come out soon.

It’s hard to know just how much that urgency has to do with money, but it’s a safe bet that some of it does. APA revenues are down, largely because drug companies have cut back on their advertising in the APA’s journals. The organization is losing membership. Since January 2010, in fact, it’s dropped by two thousand members, more than five percent. They say they’ve invested $25 million in DSM-5, and clearly they are hoping to reap rewards from it similar to the $104 million and counting that the DSM-IV has brought in–an average of 10 percent of the APA’s revenue over the life of the book. Whatever the proportions, financial need plus challenges to the profession’s credibility add up to an APA with a burning desire to put out a DSM that is different from the previous ones.

Which is the reason I feel sorry for them. A little. Because, as onetime head of the National INstitute of Mental Health and former provost at Harvard and neurobiopsychiatrist Steve Hyman puts it, they have to try to fix the plane while it is in the air. Which means they not only have to keep the thing from crashing and burning, they also have to keep the passengers from freaking out. They have to keep the smiles on the faces of the flight attendants and the calm authority in the voices of the pilots as they try to explain what all that banging and swearing is about. Otherwise, the passengers might ask for parachutes or just demand that they land the damn plane and let them go Greyhound.

It’s like trying to thread a camel through the eye of a needle. Even as it admits that its mental disorders don’t really exist, the APA has to find a way to maintain the public trust. The honest way to do this would be to help people understand what it means to be diagnosed with a “fictive placeholder” rather than a real disease, to talk openly and helpfully about the differences between a depression diagnosis and a diabetes diagnosis, rather than continually trying to insist that they are the same kind of beast. But they would have to count on people’s intelligence to do that, and that is never a safe bet. So instead they bob and weave and prevaricate and do everything they can to control the narrative, as we say these days.

And recently, these efforts took a strange turn, one that shows for once and for all that the APA is a corporation, and like every corporation, will put its interests and those of its stakeholders over the interests of everyone else.



3 Responses to “Pity the poor American Psychiatric Association, Part 1”

  1. Suzy Chapman says:

    Many thanks, Gary, for these commentaries.

    On January 12, Allen Frances published a follow-up on “DSM5 in Distress” blog, hosted at Psychology Today:

    DSM 5 Censorship Fails
    Support From Professionals and Patients Saves Free Speech

    “Last week I described the plight of Suzy Chapman, a well respected UK patient advocate forced to change the domain name of her website by the heavy handed tactics of the publishing arm of the American Psychiatric Association. The spurious legal excuse was commercial protection of the ‘DSM 5’ trademark; the probable intent was to stifle one of the internet’s best sources of DSM and ICD information. This bullying could not have come at a worse time – just as final decisions are being made on highly controversial DSM 5 proposals and with the third and final draft due for release this spring. This is precisely when a ragged and reckless DSM 5 can most benefit from the widest and most open discussion…”

    Read follow-up blog here:



  2. Richard Preisman says:

    Your Jan. 30 op-ed piece on this subject in the NY Times is helpful and well thought out. The APA uses the term “disorder” rather than “disease” as a way of conceptualizing what sort of problems someone has when they come to a professional’s office. It allows the professional to think about, study, and, potentially, be more helpful. The term has both disease and non-disease implications. Some terms, e.g., delirium amd dementia, have strong disease implications;some do not,but still are problems.That any attempt to conceptualize psychological problems will have political, financial, and legal implications is inevitable. Misunderstandings and mistakes are a given. I doubt, however, that those professionals who spend much effort in grappling with these difficult problems,have direct financial gain from the sale of the APA manual.You have financial gain from critiquing the effort, which may skew your ideas. Perhaps you should donate all the proceeds from your writing on the subject to avoid conflict of interest (just a thought). Please keep up the interesting writing.

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