Category Archives: DSM-5

The Real Trouble With DSM-5

By Liah Greenfeld

Let us take a little break from the discussion of the historical development of modern emotions and modern mental disease—that is, of the modern mind-—pursued in the previous posts of this blog, and instead focus on the present. May 22 is the official publication date of the much-talked-about DSM-5, a significant day for all who are in any way concerned with mental health, patients as well as professionals who are trying to help them, and therefore for many in the Psychology Today community. The manual has been subject to severe criticism for months preceding its publication; it appears that hardly anyone has a good word to say about it, the time and effort spent in its preparation seems to have been largely wasted. The poor baby is likely to be dead on arrival, stillborn, its own family having turned away, unwilling to embrace it. Just a week ago the mighty NIMH all but completely renounced it.

But why is it such a disappointment? And who or what is to blame for the problems with DSM-5? The answer to the first question, I would say, lies not in anything DSM-5 contributes to the previous versions of the manual (whether in terms of additions or subtractions), but in what it does not change in them at all. The answer lies in that it does not solve the fundamental problem of psychiatry and psychology, i.e., does not provide them with the understanding of the human mental process—tthe mind—healthy or ill. This is, obviously, not a problem which the DSM-5 creates, or which was created by any of the preceding versions of this document. It is the problem at the core of the psychiatric/psychological/mental health establishment in its entirety-—both its research and its clinical branches, and including in the first place its central, most powerful, and richest institution, NIMH.

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The Medicalization of Emotional Life

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Jeremy Safran in “Psychiatry in the News“:

It is one thing to hypothesize that psychological and emotional problems are associated with changes at the biological level (e.g., specific patterns of brain activity or levels of neurotransmitters) or that symptom remission is associated with biological changes. It’s another to assume that the underlying causes of mental health problems are always biological in nature and that meaningful improvements in treatment will only take place when we can directly target the relevant brain circuitry. While it may be the case that biological factors play a more significant causal role in some mental health problems (e.g., schizophrenia) than others, the assumption that the major causal factor for mental health problems is always biological is a form of simplistic reductionism.

I want to be perfectly clear that I do not question the potential value of brain science research. What I do question is the single-minded emphasis on brain science research to the virtual exclusion of all other forms of mental health research. The new NIMH paradigm for research means that the amount of funding available for the development and refinement of treatments such as psychotherapy that are not targeted directly at the brain circuitry (although they do influence it indirectly), is likely to continue to shrink. It is important to recognize that funding priorities shape the programs of research pursued by scientists, and thus the type of research findings that are published in professional journals and disseminated to the public. This in turn shapes the curricula in psychiatry and clinical psychology training programs, which shapes the way in which mental health professionals understand and treat mental health problems. It also influences healthcare policy decisions and the type of coverage provided by third party insurers.

In concrete terms, the explicit NIMH policy shift is likely to mean that despite the large and growing body of evidence demonstrating that a variety of forms of psychotherapy (e.g., cognitive therapy, interpersonal psychotherapy, psychoanalytic therapy, emotion focused therapy) are effective treatments for a range of problems, we are likely to continue to see a decreasing availability of the already diminishing resources that can provide high quality psychotherapy for those who can potentially benefit from it.

Psychiatry: Time for a Paradigm Shift

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The Division of Clinical Psychologists (DCP) of the British Psychological Society Time for a Paradigm Shift Position Statement, May 13, 2013: “The DCP is of the view that it is timely and appropriate to affirm publicly that the current classification system as outlined in DSM and ICD, in respect of the functional psychiatric diagnoses, has significant conceptual and empirical limitations. Consequently, there is a need for a paradigm shift in relation to the experiences that these diagnoses refer to, towards a conceptual system not based on a ‘disease’ model… This position… recognises the complexity of the relationship between social, psychological and biological factors. In relation to the experiences that give rise to a functional psychiatric diagnosis, it calls for an approach that fully acknowledges the growing amount of evidence for psychosocial causal factors, but which does not assign an unevidenced role for biology as a primary cause, and that is transparent about the very limited support for the ‘disease’ model in such conditions.”

Oliver James, “Do we need to change the way we are thinking about mental illness,” The Observer, May 13, 2013: “While there is some evidence that the electro-chemistry of distressed people can be different from the undistressed, the Human Genome Project seems to be proving that genes play almost no part in causing this. Eleven years of careful study of our DNA shows that differences in it do not explain mental illness, hardly at all.

Liah Greenfeld:

DSM-5’s approach is similar to attempting to salvage a house, falling apart because it is built on an unsound foundation, by adding to it a fresh coat of paint and new shutters. What Mind, Modernity, Madness does, in contrast, is to dismantle the structure, establish a sound foundation, and then rebuild the house on top of it. I begin by questioning and analyzing the fundamental diagnostic categories themselves, consider them against the existing clinical, neurobiological, genetic, and epidemiological evidence, bring into the mix the never-before-considered cultural data, and on this basis propose that the two (schizophrenia and manic-depressive illness) or even three (schizophrenia, manic depression, and unipolar depression) discreet diseases are better conceptualized–and therefore treated–as the same disease, with one cause, which expresses itself differently depending on the circumstances in which this cause becomes operative. Psychiatric epidemiologists, at least, have long suspected that “the black box of culture” is an important contributing factor in these diseases. However, as the phrase indicates, they lack the means to understand or even examine its contribution. By unpacking the “black box” (and showing, specifically, how it is reflected in the logically necessary structures of the mind, such as identity, will, and thinking self), I add a missing yet essential dimension to the diagnostic tool-kit, which the DSM-5, like the previous editions, disregards.

What’s Really Wrong with DSM-5

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By Liah Greenfeld

The essence of the DSM-5 consists in the modifications it introduces in the extensive psychiatric nosology, specifically adding diagnostic categories to diseases of unknown biological origin and uncertain etiology. But the real problem lies much deeper – in the understanding of such diseases itself. It is the problem with the old, fundamental, and universally accepted diagnostic categories of thought disorder- vs. affective disorders, or schizophrenia vs. manic and unipolar depression, on which all the other diagnostic categories of mental illness of unknown etiology, new and not so new, are based. DSM-5’s approach is similar to attempting to salvage a house, falling apart because it is built on an unsound foundation, by adding to it a fresh coat of paint and new shutters.

What Mind, Modernity, Madness does, in contrast, is to dismantle the structure, establish a sound foundation, and then rebuild the house on top of it. I begin by questioning and analyzing the fundamental diagnostic categories themselves, consider them against the existing clinical, neurobiological, genetic, and epidemiological evidence, bring into the mix the never-before-considered cultural data, and on this basis propose that the two (schizophrenia and manic-depressive illness) or even three (schizophrenia, manic depression, and unipolar depression) discreet diseases are better conceptualized–and therefore treated–as the same disease, with one cause, which expresses itself differently depending on the circumstances in which this cause becomes operative. Psychiatric epidemiologists, at least, have long suspected that “the black box of culture” is an important contributing factor in these diseases. However, as the phrase indicates, they lack the means to understand or even examine its contribution. By unpacking the “black box” (and showing, specifically, how it is reflected in the logically necessary structures of the mind, such as identity, will, and thinking self), I add a missing yet essential dimension to the diagnostic tool-kit, which the DSM-5, like the previous editions, disregards.