The DSM-5 - What Went Wrong

I have now finished issuing my grades for the homework handed in by the DSM-5 Task Force concerning their proposed revisions to the depression and bipolar diagnoses. My two introductory articles included in the title, “Rip It Up and Start Over.” Then I issued nine report cards, three for depression and six for bipolar.

I handed out grades in a total of 39 assignments, including F-minus (at 17) and F (8), plus a “no-grade” in a case where an F-minus would have been far too generous. Throwing out my four incompletes and three “no-grades” for extra credit, the fail rate was a stunning 81 percent. A lone B was my highest grade.

So what went wrong?

In an earlier piece, I brought up that the fact that the DSM-5 operating parameters were far too restrictive, involving an impossible burden of proof for even minor changes. The DSM-5 operated under the mistaken assumption that they were drafting a research paper that would be read by maybe 30 people instead of putting together a real world manual that would be relied on by millions worldwide.

In short, the DSM was never meant to be a science project. In the real world, we proceed on the best information we have available to us. This information may not always be “scientifically valid,” but it does yield results that are both useful and credible.

Instead, we bore witness to DSM-5 work groups tripping over their own feet. For instance, the draft explicitly recognized that “the current DSM-IV-TR diagnosis schizoaffective disorder is unreliable,” yet did nothing to make it reliable.

This was repeated throughout, though usually implicitly. Thus 30-year errors that defied both science and common sense (such as artificially separating out unipolar from bipolar) were being perpetuated. Thus, easy fixes with at least some measure of validity, that would lead to more precise diagnoses and save lives, were being excluded.

Other factors were at play, too. Let’s discuss “paradigm freeze.” The DSM-5 pays homage to scientific validity, but thanks to Thomas Kuhn and others we know that the quest for knowledge is hardly governed by disinterested scientists rationally sifting through the facts. In reality they are operating within their own particular conceptual frameworks (paradigms) that govern how they think.

The various DSM-5 work groups drew from the top experts in the field, but this was a fairly homogenous bunch, working within the same specialty, with similar professional backgrounds, operating off the same set of beliefs, inclined to nitpick at best. The field’s notable boat-rockers, as it turned out, were conspicuously absent. (Why wasn’t Hagop Akiskal on the mood disorders work group? Or, at the very least, one of his Facebook friends?)

Thomas Kuhn emphasized that paradigm shifts are not initiated by science’s in-crowd. Rather, they are brought about by outsiders - young practitioners and those operating in different fields. That shift is only a decade or two off in psychiatry. What needs to happen is for our nascent brain science and its allied disciplines to mature, along with new ways to explain old behaviors.

Then, instead of depression or bipolar or schizophrenia, we’ll be treated for things like “surprachismatic nuclei disease” and - supreme irony - “neurosis.”

I have been to public forums where the DSM has been debated, and I know for a fact that those on its working groups are fully aware of the impending shift. Indeed, some are even leading it. But this awareness has only seemed to immobilize them. They see the car approaching, but are frozen in its headlights.

In the meantime, we with the most at stake can hardly afford to wait for the inevitable paradigm shift. Mental illness kills. Simple. Making the changes we need to the DSM right now will hardly satisfy the conceits of scientists (old paradigm or new), but it will save lives.

Can someone explain this simple fact to the DSM-5 people?

Previous report cards:

My DSM-5 Report Card: Grading Bipolar - Part VI
My DSM-5 Report Card: Grading Bipolar - Part V
My DSM-5 Report Card: Grading Bipolar - Part IV
My DSM-5 Report Card: Grading Bipolar - Part III
My DSM-5 Report Card: Grading Bipolar - Part II
My DSM-5 Report Card: Grading Bipolar - Part I
My DSM-5 Report Card: Grading Depression - Part III
My DSM-5 Report Card: Grading Depression - Part II
My DSM-5 Report Card: Grading Depression - Part I

Coming soon: Grading Personality Disorders