This post will begin a several article attempt to explain the last few years’ controversy about the publication this last year, of the long awaited, DSM-V manual of the American Psychiatric Association. This book unknown to persons outside the “mental health professions” in the Western and many other parts of the world, is a mystery. Yet in the media in many countries for the last 2-3 years especially, there has been almost the hoopla associated with the anticipation of the early adopters of some tech company’s latest gadget, computer, or smartphone.
The title is not easy to understand either. “DSM” stands for “Diagnostic and Statistic Manual.” Years ago as a psychiatrist, when I was first introduced to this mandatory tool of my trade, I thought to myself that the title certainly discouraged opening and reading the book. Talk about boring and authors/publisher going out of their way to not “hook” the readers’ interest! It certainly did not live up to the interest kindling title in the 1960’s of his Yippie leader, Abbie Hoffman, Steal This Book that set the new standard for unforgettable book titles in those wacky times.
In the early days of modern psychiatry, beginning after World War II, the mental health field was peppered with several different systems for naming and classifying (diagnosing) mental illness conditions. Medical groups tended to use the Standard Classified Nomenclature of Disease, while the Veterans’ Administration Hospital system, then growing at a phenomenal rate in size and importance because of the hundreds of thousands of WWII veterans needing treatment medically and psychiatrically, used another. Within a few years after WWII, the American Psychiatric Association saw the need for a unitary, standard, universal common system of naming and describing mental illnesses so that everyone would speak the same language. This developed against the long standing historical backdrop that in Europe and the United States, since the late 1800’s psychiatrists in asylums, had spent decades developing many schools of description and diagnosing from the psychoanalysts trained by Freud’s circle, to the “alienists” as psychiatrists working in public “state hospitals,” seeing mostly the chronically psychotic patients, were called in those days. For instance, Eugen Bleuler of Switzerland and Emil Kraeplin of Germany had two different systems of classifying the two major psychotic illnesses, schizophrenia and manic-depressive psychosis.
DSM-I developed from a task force, in reality a large working committee of prominent American psychiatrists, and was published in 1952. DSM-I divided mental illnesses into categories derived from the dominant scholarly thinking of psychoanalysis, into the neuroses (emotional conflicts), the psychoses, and character disorders. One of the controversies that seems quaint now was that over what to call one of the great concerns of the times, given the aftermath of the two Great World Wars of the early to nearly mid 1900’s, the after effects of experience war, battle, death and chaos of the average soldier, air man, marine, etc. “Combat Exhaustion,” was replaced by “Gross Stress Reaction.” The other terms popularized by writers such as Ernie Pyle and Bill Maudin of WWII, were better known of course by the public, such as “shell shock,” or “combat fatigue,” or “combat neurosis,” all popularized in Hollywood’s hundreds of war movies that came out after World War II especially that boosted the careers of many growing male movie stars such as John Wayne and Audie Murphy.
DSM-II was published in 1968, had many more disorders, actually 182, was 136 pages long and still retained the overall “psychodynamic” or psychoanalytic emphasis. It relied heavily on the concept of internalized of “neurosis” for its classification of non-psychotic, non-character disordered conditions such as depressive neurosis, obsessive compulsive neurosis, etc. It introduced the new topic or section on childhood and adolescent diagnoses for the first time. It also had many of the quaint and discretely whispered forbidden sexual perversions or deviations from the late Victorian era of psychiatry such fetishisms voyeurism, exhibitionism, and of course, homosexuality as a psychiatric disorder [more on that controversy in a later post].
The real revolution began in the 1970’s and 1980’s when large scale epidemiological studies done by European psychiatric research groups, especially in Britain under Dr. J. K. L. Wing, in conjunction with population-diagnostic survey studies done by American psychiatric teams, showed there was a great discrepancy between the rates of diagnosing certain conditions between American and European practitioners. American psychiatrists diagnosed far more schizophrenia, while European psychiatrist diagnosed more manic-depressive illness in the patient populations. Fortunately instead of fighting and squabbling over such differences, the researchers decided to try research out and delineate from whence these differences sprang. It turned out that the American practitioners were largely wrong and American psychiatry was way under diagnosing the “affective” or “mood” disorders, now called the group of “bipolar” conditions.
This set off years of research, comparing case histories and patient family histories and every other kind of data available in those early years of more empirical and less descriptive psychiatric approaches. A new kind of research, anchored by more modern statistical methods that really did not exist till the 1960’s and 1970’s, and by the early days of being able to analyze larger amounts of data with the aid of the latter generations of mainframe computers. The use of a new technique of pulling categories more scientifically out of huge numbers of cases, through a technique called “symptom factor cluster analysis,” came into prominence. This permitted researchers to more reliably group types of patients into more reliable diagnostic categories since their signs and symptoms cross correlated more reliably, or to use clearer language, were very similar.
The result of this approach DSM-III was nothing short of revolutionary. It threw out most of the psychodynamic concepts and naming conventions such as the neuroses. American psychiatry then largely suddenly split into two camps, psychoanalytic and the new scientific, “medicalized,” psychiatry that later came to be called biological psychiatry. [That trend will also be explained in a later post on all this]. DSM-III was published in 1980 after its six years of research and authoring. To quickly conclude this introductory outline of the history, DSM-R, a revised edition came out in 1987, while DSM-V came out in 2013. This Fifth edition was long delayed and had many controversies and I shall attempt to highlight some of them, using them to illustrate the wrenching dilemmas that psychiatry and by extension, most of the mental health disciplines face now. It is fortunate that for the most part, these controversies that mirror evolutionary forces, the uncertainty caused by the avalanche and explosion of scientific knowledge, are discussed out in the open as they should be. The aim of controversy should not be to win and dominate as so often seems to be destructive tenor of our times forced upon us all by the corrosive scorched earth politics practice nowadays, but to resolve open questions and demonstrate through the answers from unbiased research that will help us all.
I shall suggest to the reader, representative authors, books and readings to supplement these, again arcane, esoteric posts on this somewhat obscure subject. But the ultimate aim will be educate the interested reader as perhaps what all this means for our evolving view of the modern person in the more modern, complex and stressful world. Some of the controversies are still unsettled in the public discourse and set off bitter national disputes, political, religious and legislative battles that endanger at times, our cherished democratic ideals of unfettered discourse, fair consideration of different points of view and show the influence of fear of the modern, more scientific and less certain modern unknown future that all cultures are facing in many forms all over the world.