The bible of Psychiatry, The Diagnostic and Statistical Manual of Mental Disorders (DSM), is the standard reference text by which psychiatric disorders are classified. Every now and then, the psychiatric community revises the manual; the current version, DSM-IV was published in 1994 and in 2000 revisions of the text were added (hence the clumsy term DSM-IV-TR) but the categories of psychiatric disease remained unchanged. At the moment, a committee is hard at work developing a new version, DSM-V, and the issue has morphed from scientific enterprise to public melodrama.
Over at H-Madness, a blog devoted to the history of psychiatry, the historian Hannah Decker has a wonderful post detailing the trials and tribulations of the controversies currently embroiling the production of DSM-V. Entitled A Moment of Crisis in the History of American Psychiatry, Decker’s post covers all of the usual territory, some of which we have discussed previously (here and here). It bears repeating that the biggest challenge to the endeavour is the lack of objective criteria for defining psychiatric diseases: until neuroscience provides this clinical specialty with concrete insights into the relevant changes in human neurobiology that accompany psychiatric disease, the field will continue to be on shaky ground, defining and redefining ‘syndromes’ composed of constellations of symptoms rather than clearly understood alterations which result in pathology.
The history that Decker documents is well worth reading by anyone with an interest in how psychiatry arrives at its provisional conclusions, but the part that caught my eye was when Decker shared her concluding observations:
The APA leadership was slow to assess and respond to the strong voices and skillful arguments of Robert Spitzer and Allen Frances and has learned a bitter lesson about the adroit use of the Internet.
The role of the Internet in popularizing and spreading the arguments and charges made by Robert Spitzer and Allen Frances cannot be overstated. Without the Internet, the ease and rapidity of their frequent attacks and challenges would have been impossible. It is worth repeating the trite observation that the Internet is the printing press of the 21st century, well adapted to fomenting upheavals.
I have not documented the innumerable blogs the many lay advocacy groups sent to their members nor the fervid online discussions of controversial matters by the public at large. Examples of the latter would be the proposed autism spectrum under which Asperger’s Syndrome would be subsumed or the wished for inclusion in DSM-5, by scores of divorced fathers, of the diagnosis of Parental Alienation Syndrome. The attempt by the public to weigh in on scientific decisions is here to stay. The only question remaining is how scientific and medical groups are going to react to ever-louder lay voices which will only increase as they are facilitated by Facebook and Twitter or other social and professional networking sites.
This is really quite an interesting observation and bears further consideration.
Inclusion of the public in determining the course of psychiatric diagnosis is not unprecedented: in 1973, the APA Board of Trustees removed homosexuality as a category of psychiatric disease from DSM-II, and opponents of this decision characterized it as a triumph of politics over science. But since 1973, DSM has grown dramatically (DSM-II is the thin amateurishly bound book at the top of the stack in the image at the top left of this post) and psychiatric diagnoses have become so widespread in modern society that nearly everyone knows someone who has been so characterized (six degrees of separation are no longer required). With the tentacles of psychiatry fenestrating the lives of so many in the absence of objective criteria, it is no wonder that the public feels strongly about the outcome of the DSM-V deliberation process.
The forces that have led to this course of events include, at a minimum, the following:
1. The decline of paternalism. In medical bioethics, there has been a sharp turn away from paternalism towards patient autonomy ever since Beauchamp and Childress published their classic work Principles of Biomedical Ethics in 1979 (now in its fifth edition). By including the voice of the patient in medical decision making, bioethics has had a significant impact upon the lives of countless patients. Nowhere is that more important that psychiatry, but in many instances, patients with the symptoms that lead them to visit a psychiatrist are not in a strong position to object. Thus, it may be argued that paternalism in psychiatry remains problematic, both from the perspective of the patient and the physician.
2. Democratization of power. Intellectually linked to paternalism is the increased recognition of power relationships in society. There is a long history of power flowing naturally to people with expertise, but this view is increasingly being challenged, most notably in Paulo Freire’s conception of the democratization of education.
3. Social Networking. Nikolas Rose speaks powerfully to the idea of Biological Citizenship, a pheonomenon that emerges from the recognition by individuals that they share selected biological traits with others, that they are members of a community. These communities increasingly utilize the internet to find each other, to share ideas, and as we have seen in the DSM-V battle, to wield the power of the citizenry in shaping the course of their own futures.
4. Follow the Money. The recognition that there are significant economic interests at play, especially insofar as provision of a diagnosis in DSM allows physicians to prescribe medications and, at least in many instances, requires insurance plans to reimburse both for the visit with the physician and the costs of the medication. The best documentation of this phenomenon is found in Christopher Lane’s book Shyness. There is no reason to think that the pharmaceutical industry is not going to work diligently to expand disease classifications in DSM-V.
5. Power of the Internet. These themes intersect quite remarkably with the power of the internet to, in the words of Pierre Levy, liberate public expression. Manifest in the myriad special interest groups that pop up like mushrooms after an evening rain, the internet forces transparency upon power elites such as the architects of DSM-V.
It is fascinating to watch as one more attempt by the psychiatric community to guess determine what is and is not a disease plays out under the watchful gaze of an activist public emboldened by the power of social networking. The forces at play are not to be underestimated.
Image Credit: Psychology Today
Hat Tip to Elana Brief for the reference to Paulo Freire