Orderer of Disorders

The January 3 New Yorker includes a revealing profile of Robert Spitzer, the main driving force behind the landmark third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. The article, by Alix Spiegel, makes clear that the DSM, widely viewed as a scientific taxonomy, is little more than a compilation of the conventional wisdom among the handful of psychiatrists who play an important role in shaping the text--or, in some cases, the whims of one guy with a typewriter:

In 1974, Roger Peele and Paul Luisada, psychiatrists at St. Elizabeths Hospital, in Washington, D.C., wrote a paper in which they used the term "hysterical psychoses" to describe the behavior of two kinds of patients they had observed: those who suffered from extremely short episodes of delusion and hallucination after a major traumatic event, and those who felt compelled to show up in an emergency room even though they had no genuine physical or psychological problems. Spitzer read the paper and asked Peele and Luisada if he could come to Washington to meet them. During a forty-minute conversation, the three decided that "hysterical psychoses" should really be divided into two disorders. Short episodes of delusion and hallucination would be labelled "brief reactive psychosis," and the tendency to show up in an emergency room without authentic cause would be called "factitious disorder." "Then Bob asked for a typewriter," Peele says. To Peele's surprise, Spitzer drafted the definitions on the spot. "He banged out criteria sets for factitious disorder and for brief reactive psychosis, and it struck me that this was a productive fellow! He comes in to talk about an issue and walks away with diagnostic criteria for two different mental disorders!" Both factitious disorder and brief reactive psychosis were included in the DSM-III with only minor adjustments.

DSM-III was supposed to make psychiatric diagnoses reliable--i.e., consistent from one practitioner to another. As Spitzer himself concedes, this goal remains elusive. Meanwhile, as Spiegel notes almost in passing, the more important question of validity--whether the "disorders" described in the manual correspond to real entities with similar causes and solutions--has been addressed hardly at all.

"One of the objections was that it appeared to be more authoritative than it was," a psychiatrist who worked on both DSM-III and its revision tells Spiegel. "The way it was laid out made it seem like a textbook, as if it was a depository of all known facts. The average reader would feel that it carried great authority and weight, which was not necessarily merited."

Comments

[Pavel]

The DSM is something of a two edged sword.

On the one hand it's completely a servant of the zeitgeist. Disorders appear largely as a response to medication, not the other way around. "Harried housewife syndrome" was still on the books in the '70s and didn't come about until a brilliant marketing campaign by Roche made it *seem* real.

On the other hand, these patently ridiculous "syndromes" are what give many of us a level of access to drugs that's the next best thing to repealing prohibition.

[alkali]

The article, by Alix Spiegel, makes clear that the DSM, widely viewed as a scientific taxonomy, is little more than a compilation of the conventional wisdom among the handful of psychiatrists who play an important role in shaping the text ...

This should not be surprising. One of the purposes of creating a compilation like DSM-III was to facilitate posing questions like, "Are disorders A and B really the same disorder?" and "Does disorder C really describe two different disorders?" and testing answers to those questions. If DSM-LXIV looks night-and-day different from DSM-III, it won't mean that putting DSM-III together was a bad idea.

By way of comparison, the great biologist Linnaeus went through nine editions of Systema Naturae in his lifetime; the first was a pamphlet and the last was several volumes long.

[thoreau]

alkali-

Good point! Standardizing terminology can be useful regardless of whether the practicioners of a discipline are working from bad assumptions. You can't really pose a question like "Is disorder X fake?" or "Are disorders Y and Z the same?" if there's no commonly accepted definition for any of the disorders in question. Well, you could, but if every researcher is working from a different definition it would be hard to compare findings and sort out what's happening.

[Sorwell]

Not too mention that each new (by which I mean, "bogus") disorder you come up with provides more rationale for the field. Thus it provides rationale for a paycheck..

[Captain Awesome]

So when will psychologists create an account based wiki-DSM that allows contiguous peer reviewing?

[Dogzilla]

The DSM pretends to describe "diseases" or "disorders", when really it is just describing patterns of behavior. Read it with the same sense of humor and skepticism as when reading "120 Days of Sodom" and it will make more sense.

[matthew hogan]

I saw psychiatrists unable to diagnose an obvious paranoid schizophrenic because the symptoms did not fall within a DSM arbitrary period and the age did not fit in and theories (contradicted by the medical literature) on earlier episodes didn't fit.