A medical disaster hit US-psychiatry 40 years ago, in the form of the DSM-III, the so-called psychiatrists’ bible. The trouble is, no one checked then, whether the DSM’s axioms were medically sound — they’re not. I sent the following academic paper to the leading psychiatric journal, and they said it was “fun” but not “rigorous” enough for them to publish. The real reason is they daren’t. Read what I wrote, and see what YOU think. Then try asking any other medical professional of your acquaintance if they too would be as happy as DSM-psychiatrists are “to be neutral with respect to theories of etiology”.
“The DSM after 40 years — a medical help or a hindrance?”
Let’s take psychiatry out of its chamber of secrets, and into the clinical sunlight. There’s no doubt that this was one of the aims the American Psychiatric Association (APA) had in mind, in publishing the DSM-III in 1980. But how successful has it been? Doubts have been raised, most recently in a Report by the Belgian Superior Health Council (2019) which concludes that “the literature suggests that a biomedical approach does not, as hoped, reduce stigma and discrimination.” Rather remarkably, its authors go even further — their paper’s very title “advises against the use of the DSM categories”. In other words, it actually recommends psychiatrists to stop using the DSM altogether. Bold and controversial advice — 40 years is a long time for any psychiatric regimen. Where does this recommendation come from? How might we benefit? Should it be implemented? Can it be justified, medically? These are significant clinical questions, and call for calm careful analysis.
The hope in 1980 was that clarity of psychiatric definitions would enable better communication between doctors, administrators and patients. Much effort, and basic scientific research has gone into this project since it’s inception 40 years ago. Take one example, PTSD. This new term brought enormous clarification to an old disease, and has indeed helped a number of court cases to healthier conclusions. The judge, or jury, needed only to hear which of the categories of symptom listed there, were present, together with a useful guide as to severity in each case. Once this was arrived at, the presence (or absence) of a solid psychiatric element in the case, became irrefutable. The entire legal basis of the criminal trial in the 1990s, of the Parkhurst Prison (UK) escapers, for example, was electrified by the application of the DSM criteria for PTSD [personal communication].
But take a closer look. The full title for PTSD is Post-Traumatic Stress Disorder. Rather a mouthful. If the aim had been for a simpler, clearer diagnosis, why not Trauma Reaction? Various well known traumas would then follow naturally — Grief Reaction, Stress Reaction, Abuse Reaction. Had this diagnostic label been simplified like this, it would have added greater clarity as to where the current symptoms came from. More, what had earlier been known simply as Shell Shock (self-explanatory in its own right), became PTSD, in DSM-III. Had anything been gained, clinically? Or was this just adding unnecessary complexity?
Medical practice is infinitely complex, so any help from the structure of diagnostic labelling is to be warmly encouraged. Failure to replace ‘Post-Traumatic Stress Disorder’, say, with the much simpler ‘Trauma Reaction’ (which tells you what it is), is less than helpful. So why did the APA do this? A golden opportunity to bring greater clarity to psychiatry seems to have been missed. Why? For those with time enough to read the small print, the answer is there in the DSM itself — out of the blue, the APA states that the term “reaction” is no longer to be used in medical practice. Thus in DSM-IV, page xvii, we find “DSM-II was similar to DSM-I but eliminated the term reaction.” However, had this rule been strictly applied, even PTSD itself, which is obviously a ‘reaction’ to something external, would have had to be omitted, as has already happened to the other four ‘Reactions’ just listed, none of which appear in any later DSM, as prevailing psychiatric practice indicates they should. Not a strong clinical position — weakened further by the fact that DSM-II itself, is actually replete with ‘reactions’, as was my psychiatric clinic.
To those trained prior to 1980, this arbitrary rejection of ‘reaction’ would seem to justify the expletive — an ‘ex-cathedra statement’ — that is to say, something you are required to believe without question. In general medicine, all disease is usefully thought of as a reaction of that individual to a given noxious event. 100 people fall in a ditch — if only 80 break their leg — how do you explain the difference? It’s a difference in reaction.
Patient reaction is thus a key part of all medical practice, whether psychiatric or otherwise. The person in front of you is unique, they differ, they have powers and weaknesses all of their own — in particular, they react differently. It’s a commonplace in medical practice that some react to parental bereavement without turning a hair, others with gruesome, directly attributable sequelae. When re-formulating diagnostic terminology, eliminating the word ‘reaction’ turns out to have been an unprecedented medical step — has the last 40 years justified it?
talk to the mind
In general medicine, it’s not possible to open a conversation with the organ at fault, the liver, for example, or the gut. In psychiatry, that’s precisely what you do. If you are interested in how an individual has reacted to a given event, ask. Indeed, it is sensible to gain as clear an impression as you can of how that particular individual does react. In general medicine, this is known as ‘Patient Agency’, what and how, the patient believes, thinks, or acts, or, significantly, reacts. And again, it’s indispensible to effective medical practice.
Now Patient Agency (like ‘health’ itself) is a polymorphic, protean notion — difficult to pin down, or define. But what is indisputable is that unless you have a “mind” in which Patient Agency can operate, the whole question is decapitated — to the comatose, or over-sedated, it has no meaning. Now you would expect a prominent psychiatric text to promote minds, in general. So it’s a surprise to find that DSM-IV does the opposite on page xxi — “The problem raised by the term “mental” disorders has been much clearer than its solution, and, unfortunately, the term persists in the title of DSM-IV because we have not found an appropriate substitute . . . “ [emphasis added].
Can this psychiatric textbook really be doubting the very existence of “mind” itself? Certainly it’s not promoting it — in other contexts, it’s no surprise to find human consciousness being celebrated as the very pinnacle of life on earth. So let’s put healthcare as a whole, into a wider perspective. People go to school to learn, and they go to doctors for help with symptoms. “Where’s this pain coming from?”, and ultimately, “Will I live?” They anticipate being helped — therapy means improving your lot — i.e. enhancing your ability to cope with what life throws at you. Why go, unless you can handle life’s vicissitudes better, as a result? In this context it amounts to empowering Patient Agency. So all of medical practice can be refocused around Patient Agency. And any doctor who ignores Patient Agency misses the whole point — they may be helping themselves, but their patients (and their Agency) are missing out.
This is especially the case in psychiatry. Patients have anxieties, depressions, psychotic symptoms — which in these terms can be represented as deficits in Patient Agency — most problems they can sort, but some are too heavy, and so call for medical help. Restoring agency, restores sanity. Psychotic symptoms in particular, mean that parts of your mental furniture have escaped your control. Either way, both “brain-insufficiency” and “a biomedical approach” undermine Patient Agency. This is the sort of medical reasoning that needs to become commonplace, to help psychiatrists decide whether to endorse the Belgian Report, and dethrone the DSM, or not. It’s a big ask.
Dr Bob Johnson.
Empowering intent detoxifies psychoses
P O Box 49, Ventnor, Isle Of Wight, PO38 9AA, UK.
Thursday, 19 September 2019
The Editors responded to this by saying it was “Fun to read but not rigorous enough for us.”, to which I responded —
Thanks for the epitaph “fun”. As for “rigorous”, the risk here is slipping into rigidity — the unexpected runaway success of DSM-III came about because of how it managed to portray consciousness. Consciousness is unquestionably the most fluid entity in the entire universe — indeed were it less so, we’d be extinct — but DSM-III didn’t stint on over-simplification, and the “mind” or what was left of it, was offered as cut and dried and as susceptible to “scientific” measurement as any number of lumps of cheese. Which it’s not — that’s its joy. (You have to ask it, if it agrees, if you want to get anywhere with it, esp when ill . . . . .)
Rigour/rigidity thus becomes the enemy of realism, and thereby of efficacy, as your January 2014 paper irrefutably showed — DSM-psychiatry prolongs psychotic symptoms by up to 10 times, over 20 years. No realistic medical speciality could survive such a devastating blow to its flagship philosophy. But, to its shame, psychiatry has done so for 6 years — when will it learn, when will it stop prolonging the disease it is being asked to curtail? This isn’t my data, it’s yours.
A medical disaster hit US-psychiatry 40 years ago. The trouble is, no one checked then, whether its axioms were medically sound — they’re not. I challenge you to ask any general physician, or any family doctor if s/he is happy with “attempts to be neutral with respect to theories of etiology” (DSM-IV page xvii)? Patient Agency and ‘reaction’ will not readily fade, either — ask, and then to publish.
This is a dragon which eats its own tail — I have not been accorded any professional “authority” to make this point, for the very reason that I actively dissent from DSM dictates. Having climbed to the top of the DSM-tree, who is bold enough to then declare that it is the wrong tree? Too few, is my assessment, so psychiatry will continue to flail, until someone does.
Nothing personal, except doing things differently does bring back the unique fascination of watching human consciousnesses re-blossom. Sherlock Holmes has nothing on this . . . . .
Ariane Bazan, et al, Belgian Superior Health Council advises against the use of the DSM categories. www.thelancet.com/psychiatry Vol 6 September 2019, 726
https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30284-6/fulltext. Full report at https://www.health.belgium.be/en/advisory-9360dsm
American Psychiatric Association (1968). Diagnostic and Statistical Manual of Mental Disorders., 2nd edn
American Psychiatric Association (1980). Diagnostic and Statistical Manual of Mental Disorders., 3rd edn
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders., 4th edn
Dr Bob Johnson Consultant Psychiatrist, (retd) firstname.lastname@example.org
Empowering intent detoxifies psychoses
P O Box 49, Ventnor, Isle Of Wight, PO38 9AA, UK.