Does the American Psychiatric Association Have a Death Wish?

The American Psychiatric Association has placed an advertorial in JAMA touting the virtues of the DSM-5. It’s a classic of the form–as they say in Texas, all hat and no cattle, or, as I say in my forthcoming Book of Woe, all clothes and no emperor.

“Many of the revisions in DSM-5 will help psychiatry better resemble the rest of medicine,” they write. This has been the dream of psychiatry since about 1847, when the APA was first founded (although then it was known as the Association of Superintendents of American Institutions for the Insane): to be taken seriously by the rest of medicine. And at least since 1917, when the APA (by then known as the American Medico-Psychological Association) heard from the head of its committee on nomenclature that diagnostic chaos was undermining the specialty’s credibility, it has seen the diagnostic manual as crucial to its standing in the medical profession, and in the world at large.

So have they succeeded? Is the title of the JAMA piece–“DSM-5: The Future Arrived”–accurate? For that matter, does it even make sense? Is arrived a past tense verb, meaning that the DSM-5 is some kind of visitation, as if the future showed up one day on the APA’s doorstep and left behind this message? Or is it a gerundive, a verb form used as an adjective? In which case, you have to wonder exactly what an arrived future looks like, and how it differs from one that is still traveling.

Anyway, I digress. Plus which I am sick of helping the APA explain itself. So I’ll let their words do the talking.

Many of the revisions in DSM-5 will help psychiatry better resemble the rest of medicine, including the use of dimensional (eg, quantitative) approaches. Disorder boundaries are often unclear to even the most seasoned clinicians and underscore the proliferation of residual diagnoses (ie, “not otherwise specified” disorders) from DSM-IV. But a large proportion of DSM-5 users will not be psychiatrists; most patients, for instance, will first present to their primary care physician—not to a psychiatrist—when experiencing psychiatric symptoms. The use of definable thresholds that exist on a continuum of normality is already present throughout much of general medicine, such as in blood pressure and cholesterol measurement, and these thresholds aid physicians in more accurately detecting pathology and determining appropriate intervention. Thus DSM-5 provides a model that should be recognizable to nonpsychiatrists and should facilitate better diagnosis and follow-up care by such clinicians.

I dare you to parse this passage without exploding your own head. No, here, let me do it for you. I’ve been taking Vaccutrix, the new drug that keeps your head from exploding when parsing nonsense, and which I would recommend for anyone unfortunate enough to have to follow the logic of psychiatric diagnosis. The first sentence promises that the DSM-5 will make psychiatry fit into modern medicine by providing dimensional measures, i.e., ways to measure disorders that resemble the methods doctors use to diagnosing other conditions. The second sentence  reminds readers that diagnostic boundaries are porous and poorly defined, which means that accurate diagnosis is hard–so hard that even the specialists can’t do it, let alone the primary care docs whom most people see first. The third sentence suggests that the best way to make this whole thing easier is to have measures like blood pressure and cholesterol that help set the diagnostic thresholds and that bring psychiatry in line with common sense, which tells us that most people’s psychological problems are extreme versions of normal behaviors or experiences.

Now here is where you would expect the APA to tell you what they have done to make diagnosing mental disorders more like measuring blood pressure and less like throwing darts, and thus to bring about the Arrived Future. But that part seems to be missing. This doesn’t stop them from leading their last sentence with “thus,” as if they had actually proved something in the paragraph. Which they did not. They merely reasserted what they wrote at the outset: that the DSM-5 is going to bring psychiatry in line with medicine. They have restated  their premise as their conclusion, using the old schoolboy trick of inserting a “thus”  in front of the topic sentence and declaring QED. It’s the equivalent of the army declaring victory in Vietnam as they beat a retreat, only in this case there aren’t videos of people clinging to the runners of helicopters taking off from the embassy roof. (At least not yet. Wait until the DSM comes out. And my book.)

I said I was tired of explaining the APA, but I can’t resist. They made this fundamental logical error for a reason–indeed for the same one that the schoolboy makes it. Which is that they don’t have any evidence, and it’s not because the dog ate their homework. It’s because there are no dimensional measures in the DSM-5. They tried to develop and implement them, but the effort was hurried and chaotic and poorly planned and ultimately soundly rejected by the membership of the APA. The dimensional approach was going to be the signal achievement of the DSM-5 (that is, after the first signal achievement, the tying of neuroscientific findings to DSM disorders, had to be abandoned for lack of evidence); it didn’t pan out. The APA leadership is understandably reluctant to own up to this fact. What is astonishing, and nearly inexplicable, unless you’ve been watching this whole train wreck unfold, is that it would insist–in JAMA, no less, the flagship product of teh AMerican Medical Association–that they had succeeded where they had failed, and to think that that little magic word–thus–would somehow win the day for them.

Does the APA have some kind of death wish?

PS=–Lest you think this is my antipsychiatrist animus speaking, this is from a source inside the DSM-5 revision effort:

This statement has no relationship to the actual DSM-5.   There are dimensional measures in the non-official Section III, however.   But that still has nothing to do with “definable thresholds that exist on a continuum.”   I would have hoped that had the reviewers of this editorial actually known anything about what DSM-5 was going to look like they would have prevented such statements from being included.

 No relationship to the DSM. In other words, no relationship to reality. In other words psychotic.

7 Responses to “Does the American Psychiatric Association Have a Death Wish?”

  1. Ivan says:

    Could it be that this piece in JAMA was ghostwritten by the PR hack the APA recently hired from DoD?

  2. Great title for the new book.

  3. Altostrata says:

    They’re recycling their rationalizations, patching them together over and over in new and non-exciting ways.

  4. […] Bernard Carroll for calling attention in his comment to psychotherapist Gary Greenberg’s blog:–which in turn refers to a paper in JAMA extolling the virtues of the soon-to-be-published […]

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