Midwest ASCP Regional Conference
July 19, 2014
The Saga of the DSM – Janice Funk PhD
“I can calculate the motions of the heavens but not the madness of men”
Nassir Ghaemi
 No treatment can work unless the diagnosis is true and valid
Mental Illness
 The split between “mental” and physical illness was highlighted by the philosopher
Descartes and stems from the Christian philosophy of the immortal soul which was
thought to reside in the pineal gland
 Difficulties measuring emotional function have impeded a modern understanding of
psychiatric disorders as physiological disease
 “Parity” in the insurance coverage reveals a return to understanding psychiatric disease as
a form of brain disease
1840 Census Data
 First American attempt to document the prevalence of mental illness
 The only categories were “idiocy” (mental retardation) and “insanity” (psychosis) Neither term
was defined
Later Forms of Classification
1917 brought the Statistical Manual for the Use of Institutions for the Insane (22 diagnoses) 1942
brought the Standard Classified Nomenclature of Disease used by the Army
1949 World Health Organization International Statistical Classification of Disease ( ICD 6)
Early Psychiatry
 Freud
 Alzheimer
 Kraepelin
Emile Kraepelin
 Created the first modern classification system for psychiatric disorders Primarily used in Europe
 Ignored in DSM 1 & 2
 Basis for DSM 3
Early Psychiatry
 Prior to 1950, diagnosis didn’t matter that much because treatment options were limited
 “Insanity” was treated by segregation in institutions
 Individuals diagnosed with “psychoneurosis” went into analysis.
William Menninger, MD
 Military psychiatrist who advocated outpatient psychiatric services for returning veterans and
rejected the idea they were insane
Midwest ASCP Regional Conference
July 19, 2014
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His work was not supported by the American Psychiatric Association which supported
hospitalization as the major form of treatment
Drug Development
 With the availability of multiple new medications hospitalization was often not necessary
 For the first time, mental patients resided in the community and with families
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With the new medications came the need for finer distinctions between multiple psychiatric
disorders
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Lack of diagnostic reliability was beginning to bother the American public
Medications for Mental Illness
The DSM
 The DSM is not a scientific document but a product of consensus by committees of
experts
DSM I
1952
 Prior to this time there were many “nomenclatures” for psychiatric diagnosis and each
was different
 This created a lot of confusion between practitioners and researchers
 DSM I appeared in 1952 and was created to develop some basic agreement in
terminology
 The DSM I divisions were neurotic, psychotic and character disorders
 All mental disorders were termed “reactions”
A Significant Change
 The DSM I committee was led by Adolf Meyer (1866-1950)
 Members of the committee were primarily psychoanalysts
 Resulted in increased reliability but no validity
DSM I
 The publication was only 130 pages long and described 106 disorders
 The DSM I described all mental disorders as non-organic, non-genetic reactions to stressful
situations.
 Any hint of genetic causes was ignored
American Psychiatry
 Although understandable, the American discomfort with genetic and biological causes
for psychiatric disease led research in the wrong direction for many years
Midwest ASCP Regional Conference
July 19, 2014
Ant i -ps yc hi at ry
 Diagnostic inaccuracies medication overdoses and the inclusion of homosexuality in the
DSM result in a national backlash against psychiatry in the 1970s
 1973 – Rosenhan experiments
The Myth of Mental Illness
 Thomas Szasz, MD went so far as to state that there was no such thing as mental illness.
Schizophrenia was just a “creative” response to stress
DSM II
 Published in 1968 - only 136 pages long
 Described 182 disorders
 Included much of the DSM I but added a section for childhood and adolescence and a
section on sexual
 disorders including homosexuality
 Got rid of the term “reaction” but DSM 2 was still based on Freudian principles
 The DSM 2 was strongly criticized from the beginning and by 1970 a committee was
formed to create the DSM-3
Scientific Knowledge vs Treatment
DSM-III
 494 pages long – 265 diagnoses
 The DSM-3 turned away from Freudianism and the concept of neurosis was minimized
 The DSM-3 was created by
 a committee without any attempt at scientific validation
 Reliable but not valid
DSM-III & Depression
 The history of DSM-3 is the key to understanding why the diagnosis of depression has
become so common in our time
 The DSM-3 created the term “Major Depression”
 Initially, DSM 3 included “Minor Depression” but this was abandoned secondary to insurance
concerns (!?!!) Thus, in DSM 3 all depression became Major Depression
 Major depression was so broadly defined as to be applicable to almost any set of symptoms
beyond complete happiness
False Epidemics
 The DSM-3 pathologized a large segment of the population once considered merely “neurotic”
and mandated their treatment with the fashionable new Prozac-style antidepressants
DSM III-R
 567 pages - 292 diagnoses
 Completely removed all references to Freudian theory
Midwest ASCP Regional Conference
July 19, 2014
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Suggested that diagnosis was mechanical and any health practitioner could use it
successfully
Increased “comorbidity”
Revisions criticized as “arbitrary”
DSM IV
 886 pages - 297 disorders
 Several personality disorders were deleted
 ADD/ADHD was added - previously called “minimal brain damage”
 Asperger’s was added and the criteria for autism was liberalized
Robert Spitzer, M.D.
 In the DSM-IV Robert Spitzer suggested adding attention deficit hyperactivity disorder
and Asperger’s
 Dr. Spitzer now states this was a big mistake and has created “false epidemics” of these
conditions
 He strongly counseled the committee to remove Asperger ’s from DSM 5
DSM 5
 The ultimate question is whether DSM 5 describes a set of illnesses or problems
associated with living
Caveats
 The DSM 5 is not a scientific document but a product of consensus by a committee of experts
The DSM system is better at categorizing severe mental disorders
 The DSM was never intended to be a guide to treatment only classification
 Many proposals for the DSM 5 were clearly more motivated by insurance issues than by
science
Number of Categories
NIMH
 Thomas Insel has requested that researchers not rely on DSM 5 criteria due to the lack of
validity
Top Changes in DSM 5
 Multiple axial system has been removed
 Separate section for pediatric diagnoses has been removed
 Asperger’s has been removed
 Sub-types of schizophrenia have been removed
 Schizoaffective disorder is described as “longitudinal”
 Delusional disorder now encompasses bizarre and non-bizarre delusions
Midwest ASCP Regional Conference
July 19, 2014
Autism
 Defined as a persistent significant deficit in social communication and social interaction
 Restricted repetitive patterns of behavior should be present
 Symptoms must begin in childhood
 Childhood disintegrated disorders are now included
 Social (Pragmatic) Communication Disorder replaces Asperger’s Syndrome
Bipolar Disorder
 Other Specified Bipolar and Related Disorder expands the diagnosis of bipolar disorder by
reducing the duration of symptoms needed for diagnosis
 This will result in an increase in diagnosis of bipolar disorder
New Depressive Disorders
 Disruptive mood dysregulation disorder (meant to reduce the diagnosis of bipolar disorder in
children)
 Premenstrual dysphoric disorder
 Dysthymia and/or Chronic Major Depression has become Persistent Depressive
Disorder
 Major Depressive Disorder is little changed
Bereavement
 DSM 4 excluded diagnosing major depression during acute bereavement
 DSM 5 recognizes bereavement as a severe stressor which can precipitate major depression
 Persistent complex bereavement disorder has been added to the DSM 5 appendix
 Medication now considered appropriate (still controversial)
Anxiety Disorders
 OCD is no longer considered an anxiety disorder
 PTSD is now a “stress-related disorder”
 Phobias require a six month duration and now take cultural factors into account
 Panic attack and agoraphobia are no longer linked
 Selective mutism removed from pediatrics and added to anxiety disorders
Obsessive-compulsive Disorders
 Now a separate category Hoarding disorder added
 Excoriation (skin picking) disorder added
 Trichotillomania moved in from anxiety disorders
 OCD secondary to drug abuse added
Trauma and Stress-related Disorders
 Stress acquired indirectly ( i.e. watching television) added Criteria for PTSD have been
liberalized
 Reactive Attachment Disorder (infant neglect syndrome) added .
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July 19, 2014
Poor Reliability
 In the DSM 5 field trials reliabilities were frequently low especially for major depression
Assorted Changes
 Dissociative disorders now include “possession -form phenomena” (i.e. demonic
possession)
 Hypochondriasis is eliminated and replaced by Illness Anxiety Disorder
 Psychological Factors Affecting Other Medical Conditions added
 Elimination Disorders added
 Gender Dysphoria added
Neurocognitive Disorders
 Replaces dementia
 Mild Neurocognitive Disorder replaces mild cognitive impairment
 Frontotemporal neurocognitive disorder added
 Neurocognitive disorder due to Lewy bodies, Parkinson’s, Huntington’s, prion disease,
HIV infection,
 Substance use
 Neurocognitive disorder due to multiple etiologies
Personality Disorders
 Cluster A
o Paranoid
o Schizoid
o Schizoptyal
Other Conditions That May Be A Focus of Clinical Attention
 Relational problems (100% of world population)
 Abuse and neglect
 Educational and occupational problems
 Housing and economic problems
 Problems related to social environment
 Problems related to crime or interaction with the legal system
Criticism Of The DSM
Limitations
 The DSM manuals reflect current limitations in our understanding of mental illness
 They are not “Bibles” but are works in progress towards an understanding of emotional
disorders
Two Manuals?
 Even a cursory reading of psychiatric literature suggests that there are two
domains for “mental disorder”
 One is a category of brain diseases s uch as schizophrenia and bipolar disorder .
Midwest ASCP Regional Conference
July 19, 2014
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The other is the category of what used to be referred to as “the human condition”
or issues of life and personal growth and what are now primarily referred to as
adjustment disorders
Psychiatry versus psychology
Overlap
 Even this distinction is problematic as PTSD appears to be both
 Remember, most people exposed to severe trauma never develop PTSD
False Positives
 The concept of mental disorder used by the DSM system leads to false positives
 There is no systematic way to separate clinical from subclinical phenomena
 Robert Spitzer is on record stating that he wrote the DSM-III with the aim of being
inclusive thinking it best to include more categories and sort out the validity later
 Once in, no one is willing to remove a category
DSM Validity
 Not So Much
Scientific Backlash
 By the 1970s, there was a significant American backlash against science in general and
psychiatry in specific
DSM 4 Committee
 The DSM 4 committee concluded that science should be the least important factor in the DSM
system
 Pragmatic, professional, economic and social considerations were considered more important
Insurance Reimbursement
 We should not be surprised that nature does not follow a classification of diseases created almost
completely...for the purposes of insurance reimbursements
Reification
 To reify means to accept as the truth something which is merely common
 Over the last 33 years constant use of the DSM has given clinicians the impression that the
categories they describe must be valid
 This is not true
We are told without solid evidence that millions of people with mental symptoms
are tragically under-treated. Although it is true that some patients with severe disorders are not
getting the help they need, mild or subclinical symptoms may not need the same treatment or
any treatment at all
A Growing Concern
 An increasing number of researcher and clinicians are becoming disturbed at this trend
Midwest ASCP Regional Conference
July 19, 2014
Diagnostic Expansion
 DSM-IV dramatically expanded the diagnostic criteria for these two categories
Poor Guide To Treatment
 All editions of the DSM clearly state that they are not intended to be guides to treatment
Clinical Utility
 Increasingly large and unwieldy, the DSM 5 lacks clinical utility and appears written for research
purposes
 NIMH has rejected the DSM 5 for research purposes leaving it hanging in limbo
 Not fit for research and lacking in clinical validity
Neither Fish Nor Fowl
 Increasingly large and unwieldy, the DSM 5 lacks clinical utility and appears written for research
purposes
 NIMH has rejected the DSM 5 for research purposes leaving it hanging in limbo
 Not fit for research and lacking in clinical utility
Joel Parish M.D.
 A critical but balanced look at the difficulties in classifying mental illness
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I cannot fault people for wanting to believe that psychiatric diagnosis is precise and scientific
and leads to specific evidence-based treatment - but they are wrong
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The greatest flaw in the DSM 5 is an expansive pathologizing of life experiences
Determining Disease State
 Recurrence, not the symptoms of depression itself, is the hallmark of psychiatric disease
 “Neurotic” depression is more like a personality disorder
 This is consistent with Emile Karepelin, Goodwin and Jamison, Nassir Ghaemi and many others
 We must learn to distinguish between depression as a disease and sadness as part of normal life
Depression:
Disease and Non-Disease
Overly Inclusive
 A major problem with our understanding of depression is that we have collapsed several
different diseases and conditions into one label
Categorizing Depression
 Major Depression
 Manic-Depression
o Unipolar Depression Bipolar Depression
Midwest ASCP Regional Conference
July 19, 2014
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o Neurotic Depression Dysthymia
Generalized Anxiety
Unipolar Depression
 Recurrent severe episodic depression Currently called unipolar depression
 Often confused with major depressive disorder
 Considered part of the manic-depression spectrum by both Goodwin & Jamison and Emile
Kraepelin
 Often occurs spontaneously but can be triggered by stress
 Appears to have biological causes - responds to medication
Absolutely No Escape
Famous People with Depression
 Depression strikes people of all ages even wealthy individuals with little stress whose
lives are not hard
Neurotic Depression: Non-disease
We Still Need This Guy
Tug-of-War
 American idea that lack of happiness is a disease
 ve r su s
 People can be sad or have a negative worldview and be without disease
Neurotic Depression
 Named in 1769 by William Cullen
 Involves distress but not delusions or hallucinations
 Includes pessimistic worldview
 A personality type
 Often result of negative upbringing
Depression - Non-disease
 Major Depression
 Manic-Depression
o Unipolar Depression
o Bipolar Depression
 Neurotic Depression
o Dysthymia
o Generalized Anxiety
Neurotic Depression
 Removed from the DSM in 1980
 Replaced by Dysthymia and Generalized Anxiety Disorder
Midwest ASCP Regional Conference
July 19, 2014
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AKA Depressive Personality
Closer to a personality disorder than a disease
Neuroticism
 Often considered a trait or part of personality
 Neurotic individuals are often anxious, angry, hostile, depressed, self -conscious,
impulsive, vulnerable, fretful
 The opposite of neuroticism is emotional stability, free of worry, calm and controlled
Neurotic Depression
 Symptoms are rarely disabling
 Usually chronic
 No cycling
 Associated with a negative world view
 Childhood issues may be present
 Symptoms rarely enough for hospitalization
 Responds well to psychotherapy
Keep me away from the wisdom which does not cry, the philosophy which does not laugh and the
greatness which does not bow before children.
Environment Still Matters
 We observe our parents cope
 We may learn ineffective techniques for dealing with life
 Neurotic coping is less effective
 Can be replaced through therapy
Environment Still Matters
 Current models of depression focus primarily on biological processes
 However, early environment, parental style and early stress play important roles in
development of mood patterns
 We need a way of re-introducing these factors into our current understanding of mood
disorders
 Without acknowledging the role of early experience, we risk mislabeling, misdiagno sing
and mistreating these patients.
Early Childhood Experience
 Poor parenting can cause children to develop coping strategies that are destructive later in
life
Emotional Injuries
 Repeated emotional injuries in childhood can lead to difficulties in attachment
 Lack of emotional support can lead to poor coping, poor self esteem and difficulty with
social skills
 These can lead to mild-moderate problems in adulthood
Midwest ASCP Regional Conference
July 19, 2014
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Symptoms include negative outlook and nervousness
Previously known as Neurotic Depression
Currently called Dysthymia and Generalized Anxiety
Proposed Guidelines for Neurotic Depression
 Depressed mood more intense and disabling but not distinct from normal sadness
 At least two but not more than four of the following:
Neurotic Depression Continued
 Chronic worries or psychological anxiety most of the day Multiple somatic complaints
 Mood generally appropriate to life circumstances
 Absence of psychomotor retardation
 Does not meet criteria for DSM Major Depressive Disorder Does not meet criteria for DSM
Major Depressive Episode
Treatment of Neuroses
 Antidepressants have some limited utility in treating neurotic depression.
 Use should be short-term and as part of a program including psychotherapy
Nassir Ghaemi, MD
 There is much that is wrong with the DSM and the way it classifies depression and much that is
mistaken about our use of new antidepressants.
 The concept of neurosis needs to be reconsidered and rehabilitated; the notion of melancholic
depression is important; our antidepressant treatments are less effective in many ways than have
been claimed
Summary
 The DSM-5 is not radically different from the DSM-4
 It does continue a long-term trend of expansion into the realm of normality
 The result has been false epidemics over diagnosis and over treatment
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Science has not yet provided much reliable or valid data regarding the nature of mental
illness
The DSM 5 is required for insurance claims but is not yet a valid description of mental
disorders
Joel Parish On The DSM
 My advice has consistently been – learn it but don’t believe in it