Biopsychiatry Illuminated

THE CANDLELIGHT PROJECT
by Bob Collier

26 January 2004
Issue 78

Non-English readers of Parental Intelligence (and, possibly, English readers of generations subsequent to my own) may not be familiar with the description of something as a 'curate's egg'.

A curate, in England, is an ordained minister who is an assistant to a vicar or parish priest, and bottom of the pecking order in the church hierarchy.

In 1895, the British humorous magazine 'Punch' featured a cartoon in which a timid curate is shown having breakfast in his bishop's home. The bishop is saying, "I'm afraid you've got a bad egg, Mr. Jones", to which the curate replies, in a desperate attempt not to give offence: "Oh, no, my Lord, I assure you that parts of it are excellent!".

From this came the literal interpretation of the phrase 'curate's egg' as "something declared to be partly good but in fact thoroughly bad", although the more popular understanding is that it means simply "something that is partly good and partly bad and consequently unsatisfactory".

The American Psychiatric Association's 'Diagnostic & Statistical Manual of Mental Disorders' - the 'DSM' - it seems to me, is a classic 'curate's egg'.

There appears to be no debate in that respect (that I've found, at least). The debate seems only to be about whether it's a 'curate's egg' in the literal sense or in the more popular sense.

Here are some points of view on that subject:

This first, unequivocal, opinion comes from the April 2003 edition of the Psychiatric Times.

Dump the DSM!
by Paul Genova, M.D.

"The American Psychiatric Association's DSM diagnostic system has outlived its usefulness by about two decades. It should be abandoned, not revised. Its primary achievement was to force American psychiatrists to recognize that not all patients presenting with florid psychoses had schizophrenia. More generally, it aimed to force the idea of operationally defined syndromes down the throat of a profession that was still, in the 1970s, dominated by the vague and archaic concepts of psychoanalysis at its American 1950s worst.

These goals have long since been accomplished, and, like the preceding analytic vagueness, it is time for the arbitrary, legalistic symptom checklists of the DSM to go. (The lag time would be about the same, 20 years or so.) Let me say at the outset that I do not wish to disparage all the hard and well- intentioned labors of the various work groups that developed the different sections of these books in their several editions or to deny the enormous amount of information summarized therein. But again, the aggregate is an awkward, ponderous, off-putting beast that discredits and diminishes psychiatry and the insight of those who practice it.

Consider the fact that your clinical practice is governed by a diagnostic system that:

is a laughing stock for the other medical specialties;

requires continual apologies to primary care doctors, medical students, residents, and the occasional lawyer or judge;

most of our thoughtful colleagues privately rail against;

insists upon rigid categories that often serve only to confuse and misinform patients and their clinical workers (sometimes abetted by televised drug advertising);

is so intellectually incoherent as to raise eyebrows among the well-educated, critical thinkers in our own psychotherapy clientele;

persuades the world at large that psychiatry no longer has anything of interest to say about the human condition.

If it were within your power to do so, wouldn't you get rid of this system?"

You can read the complete article here:
http://www.psychiatrictimes.com/p030472.html

In the same edition of the Psychiatric Times, there's a response to Dr. Genova's arguments, in defence of the DSM, from two fellow psychiatrists, Michael First, M.D., and Robert L. Spitzer, M.D.

It's worth noting that Dr. First was co-chair and editor of DSM-IV-TR and Dr. Spitzer chaired the work groups that developed DSM-III and DSM-III-R.

The DSM: Not Perfect, but Better Than the Alternative

"The author of "Dump the DSM!" paints a picture of a world that- fortunately for all of us--does not exist. The article is peppered with absurd claims about how the DSM is perceived. According to the author, the DSM is the cause of a large number of extremely serious problems, such as the precipitous decline of psychiatry in the eyes of the general public, primary care, and other specialty physicians and mental health care practitioners. The DSM is even cited as a major reason medical students do not enter psychiatry.

Apart from his own view of the DSM, the author presents no evidence to support his claim that it is universally regarded as useless to clinicians. In fact, the contrary is true. Surveys of clinicians regarding their attitudes toward the DSM have consistently shown that the DSM is generally viewed as clinically useful."

The complete article is here:
http://www.psychiatrictimes.com/p030473.html

This opinion is from Health Day News, July 18, 2003:

Study Faults How Mental Disorders Are Classified

"Serious flaws in the way doctors classify psychiatric disorders have sent drug development way off track, two scientists assert.

Specifically, the researchers, writing in the July 19 issue of the British Medical Journal, attack the Diagnostic and Statistical Manual of Mental Disorders (DSM) -- the bible for psychiatric diagnoses -- for failing to reflect the biology of different conditions.

"We need to take all of our copies of the DSM and throw them into the sea," cries Edward Shorter, lead author of the article and a professor of the history of medicine at the University of Toronto in Canada. "There are such fundamental flaws that the whole thing needs to be rethought. We need to have indications that correspond to natural, underlying disease processes.""

For the complete article, go here:
http://www.healthfinder.gov/news/newsstory.asp?docID=514219

Then there's this:

"The manual's most recent 1994 incarnation, DSM-IV, contains 374 disorders, including more "Learning Disorders": "Reading Disorder," "Developmental Arithmetic Disorder," and so on. Even allowing for the probability that some of the observations so classified, such as an inability, or near-inability, to process numbers (dyscalculia) exists, the point here is that all the various labels carry a numerical code, just like "urinary track infection" might appear on a medical insurance slip.

Some of the classifications are ludicrous. In what was intended as a humorous commentary on the DSM-IV manual by "Daily Messenger" editor Mary Syverud, she wrote, "...if your wife won't tell you that she snuck out to the outlet mall last Saturday, then she's definitely got 313.2 "Selective Mutism" ... Trust me, I am not making these things up. (That would be "Fictitious Disorder Syndrome)."

Syverud goes on to describe a panoply of "illnesses" detailed in the manual, from "Lottery Stress Disorder" (perhaps appropriately given the acronym LSD), "Chronic Tax Anxiety Syndrome," and something to ensure inclusion of all of psychiatry's Doubting Thomases, "Noncompliance With Treatment Disorder," number 15.81.

Quips Syverud: "Only a decade ago, psychiatrists said one in 10 Americans had a mental illness. Now, according to the manual half the population is mentally ill. How the other half stays sane remains a mystery."

Psychiatrist Ron Leifer concurs. Laughing at the tendency in his field to find mental illness in everything, he says:

"Everyone is neurotic. I have no trouble giving out diagnoses. In my office I only see abnormal people. Out of my office, I see only normal people. It's up to me. It's just a joke. This is what I mean by this fraud, this arrogant fraud....To make some kind of pretension that this is a scientific statement is...damaging to the culture...the more popular psychiatry becomes, the more mentally ill people there are. This is good business.""

Beverly Eakman, in 'Cloning of the American Mind: Eradicating Morality Through Education'

" ... the current DSM is a compendium of checklist diagnoses: cursory, superficial menus of symptoms in which a minimum number (for example, four of eight or three of twelve) is needed to make a particular diagnosis ... Any attempt to help patients understand themselves and to effect real change is lost in the rush to diagnose and medicate them."

Dr. Joseph Glenmullen, Clinical Instructor in Psychiatry at Harvard Medical School

"Among institutional psychiatrists and psychologists, there are two major strategies of 'treatment': drugs and behavior modification. There really is nothing else seriously discussed, and it would be fair to say that in institutional mental health 'treatment' is synonymous with 'manipulation.' ... institutional mental health's diagnoses are unreliable and invalid - and thus unscientific - rendering them more diversionary than useful. ... Know that sticks and stones may break your bones, but DSM does permanent damage."

Bruce Levine, Ph.D., 'Commonsense Rebellion: Debunking Psychiatry, Confronting Society'

From the November 2002 edition of Current Psychiatry Online:

DSM: Not our bible, but our dictionary
Randy Hillard, MD, Editor-In-Chief

"Plaintiffs' lawyers often try to get expert witnesses to acknowledge that "the Diagnostic and Statistical Manual of Mental Disorders is the psychiatrist's bible, isn't it, Doctor?" The correct answer is never to acknowledge that anything other than your professional experience and its integration with the literature is authoritative. Medicolegal considerations aside, however, DSM is more like psychiatry's dictionary than its bible because it is revised every few years."

Read the complete article here:
http://www.currentpsychiatry.com/2002_11/1102_editorials.asp

It seems to me that, at the end of the day - whether 'bible' or 'dictionary' - the DSM has created and maintains a very dangerous state of affairs, when you take into account the reprehensible behaviour that has been spawned and encouraged by its pronouncements.

There are clearly major disagreements over the DSM's meaningfulness and validity even within the psychiatric profession - yet, as my explorations have revealed, it continues to be routinely acted upon by numerous minions in the front line as if it really IS the Word of God - "It's in the DSM, so it must be right."

Going beyond merely dumping the DSM, the actor Tom Cruise was quoted this week as saying that psychiatry should be "outlawed".

That may or may not be the way to go, but it seems to me from what I've discovered over the past year that - at the very least - psychiatry has an awful lot of explaining to do. And, since the term 'psychiatrist' appears to have now become synonymous with the phrase 'sales agent for the pharmaceutical industry', making these people publicly accountable for the results they produce in terms of customer satisfaction would probably be a sensible move - and possibly uncomfortably enlightening.

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