Book of Woe, Appendix 2

And then there was the field trial idiocy.

To see whether or not new diagnoses and new diagnostic criteria really work, whether they are useful, whether they create unforeseen consequences like too-high rates of diagnosis, they are field tested. Mental health workers in hospitals and private offices use the new criteria and report back on how they worked, and based on their experience the criteria are tweaked.

Field trials were supposed to begin in May 2010. But the criteria weren’t ready by then, which gave the dissenters more ammunition, as one of their criticisms was that the process was hopelessly inefficient and behind schedule. Over the summer, little was heard of the field trials, but every time I asked a question about the vagueness of various criteria or the complexity of the process by which the APA wants to start specifying the severity of mental disorders, the answer was, Wait until the field trials. In the meantime, certain deadlines loomed that were out of th APA’s control, especially the deadline for the update of the World Health Organization’s International Classficiation of Diseases (too complicated to go into here, but trust me, if the APA doesn’t get their DSM shit together before the ICD goes to press, they’re gonnna be one sorry bunch). So the pressure was on to get the field trials under way.

Finally, in October, the APA announced in a press release that the field trials had begun. I emailed to get some details and quickly discovered that the trials had not begun at all, except for one–the pilot study, which had been under way for months and whose results would determine the final shape of the field trials. Near as I could make out, the real start date was at least two months away.

You can’t blame the APA for not wanting this information out there. But why in the world would they announce that the trials had started when they had not? Did they really think no one would ask? I can only think of two possibilities, besides the obvious, which is that they’re too arrogant to think anyone will notice or care. First possibility: it could have been a Freudian slip–an unconscious revelation of something that they did not want in the light of day, truth coming to light in the form of a lie. Second, it could have been an Orwellian assault on language, you know, when an institution has so much power that it thinks it can control the meaning of words, as in War is Peace. 

Of course, there’s a third possibility: rank incompetence. That’s the explanation I think dissenters would go with, but it just seems too simplistic to me.

5 Responses to “Book of Woe, Appendix 2”

  1. Alex says:

    Fantastic article. Not biased and certainly had a lot of interesting facts. A general distrust of pharmaceutical companies seems to be a growing concern in the minds of a younger generation. It’s just another piece of the puzzle!

  2. Theodore says:

    A good addition to a great article. I’m finishing my training in child psychiatry right now and looking at the DSM-5 proposals has generally made me ill. I am of the opinion that AACAP (the child APA equivalent) should sign off from using the DSM as its standard and just use the more flexible (and less self-regarding) ICD system. As I think about it, probably the APA would benefit from the same.
    What I wish you had mentioned either in the main article or here afterwards (though you likely have in earlier posts) is the absurdity of leading national psychiatrists talking about “normality”. Really, how can anyone ever define pathology if normality isn’t first defined? Out of curiosity, did you challenge any of the APA bigwigs to define the term?
    More to the point, even if the APA could create a sufficient compendium of all the forms of hunan suffering and organize them into coherent and distinct entities, it would still be doing psychiatry (and psychology) a disservice by perpetuating the notion that suffering of ANY type could be adequately diagnosed or assessed using a checklist.
    That, in the end, is the real story – across the country, mental health services go vastly underfunded based largely on the idea that master’s and BA level clinicians can adequately assess and treat mental illness and suffering. Hell, leave aside the undesirable niche of psychopharm that psychiatry has reduced itself to. All of this ultimately goes back to the DSM and the idea that understanding illness can come from a checklist. This idea undermines the value of psychiatrists and psychologists alike. Dr. Regier can talk about “provisional” understandings until he’s blue in the face, but the DSM’s conceptual approach is THE problem, and rewriting the book using the same approach only entrenches the problem more.

  3. Dr Andrew KInsella says:

    Actually, checklists have some real values. Many patients can be highly discursive and many have difficulty recalling their significant symptoms in the pressure of a consultation.

    Checklists can ensure that critical questions are not missed, and can jog the memory of a patient.

    In the case of Adult ADHD for instance- many patients are somewhat surprised to see that that description applies to them. However- when presented with a questionnaire that has a strong slant towards inattentive/ hyperactive/ impulsive symptoms with a relatively limited number of symptoms of anxiety or depression they understand the suggestion much better.

    I would suggest that it is bad practice to rely on a checklist in “diagnosis” but equally bad practice not to seek the support of such a useful aide.

    Of course we all know that the diagnostic model does not apply all that well to human suffering- but it has its uses.

  4. Hilary Smith says:

    I’m in the middle of reading “Manufacturing Depression” and just stumbled across your piece in “Wired” (“hey, isn’t that by that guy who wrote that book?”) thanks for two very eye-opening pieces of writing.

    as a mental health “consumer” (ick!) I’m most unsettled by the role of health insurance providers (and their billing requirements) in prompting doctors to diagnose patients with specific disorders so the doctor can get paid. it’s unfair to everybody: patient, doctor, society at large.

    I’ve heard psychiatrists argue convincingly that having an “accurate diagnosis” is essential to getting patients the proper treatment, but when there’s such a dire emphasis on labeling everybody and everything (and such inscrutable organizations in charge of the labeling) I can’t help but wonder if many people would be better off in a world without the DSM.

  5. I’m late to the party – just read your piece in my issue of Wired Magazine (yes, I pay for it). Thank you. I’m a social worker and social work professor. I’ve been wondering about DSM-5 for a couple of years. I’ve asked colleagues and no one seems to have any idea what’s going on. Our social work students need to know. Your article has given me answers. Thank you, thank you, thank you. Oh, and I’m looking forward to buying and reading Manufacturing Depression.

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