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The fascinating — and troubling — story of how the modern DSM, psychiatry’s diagnostic bible, came into being

Jon Ronson
Jon Ronson

In the current issue of New Scientist magazine, British journalist and documentary film maker Jon Ronson (“The Psychopath Test: A Journey Through the Madness Industry”) writes about what he calls the “false epidemic” of childhood bipolar disorder.

It’s one of many contentious debates swirling around the next edition, currently in production, of the “Diagnostic and Statistical Manual of Mental Disorders” (DSM), psychiatry’s official bible for identifying and diagnosing mental illnesses.

Some psychiatrists have argued that childhood bipolar disorder, which is now sometimes diagnosed in children as young as 2 years old, should not be in the DSM.

“These kids can be very oppositional, powerful kids who can take years off your happy life. But they aren’t bipolar,” New York child psychiatrist Dr. David Shaffer told Ronson.

Chaotic beginnings
What I found particularly interesting — and troubling — in the article, however, was Ronson’s description of how the modern DSM, with its checklists of psychiatric symptoms, came into being.

For the story, he interviewed octogenarian Dr. Robert Spitzer, who was a psychiatrist at Columbia University when he signed on in 1973 to edit what was then, as Ronson points out, “a little-known spiral-bound booklet … that reflected the Freudian thinking predominant in the 1960s. It had very few pages, and very few readers.”

Spitzer thought Freudian psychoanalysis was worthless, particularly since it had failed miserably to help his own “very unhappy mother.” He wanted to create a new DSM that would toss out Freud and introduce checklists of symptoms for various disorders. Psychiatrists could then match a patient’s symptoms with the checklists to make a diagnosis.

It all sounds very rational and evidence-based — until Ronson describes the process used to devise those checklists [Warning: British spellings]:

For six years Spitzer held editorial meetings at Columbia. They were chaos. The psychiatrists would yell out the names of potential new mental disorders and the checklists of their symptoms. There would be a cacophony of voices in assent or dissent — the loudest voices getting listened to the most. If Spitzer agreed with those proposing a new diagnosis, which he almost always did, he’d hammer it out instantly on an old typewriter. And there it would be, set in stone.
That’s how practically every disorder you’ve ever heard of or been diagnosed with came to be defined. “Post-traumatic stress disorder,” said Spitzer, “attention-deficit disorder, autism, anorexia nervosa, bulimia, panic disorder…” each with its own checklist of symptoms. Bipolar disorder was another of the newcomers. The previous edition of the DSM had been 134 pages, but when Spitzer’s DSM-III appeared in 1980 it ran to 494 pages.
“Were there any proposals for mental disorders you rejected?” I asked Spitzer. “Yes,” he said, “atypical child syndrome. The problem came when we tried to find out how to characterise it. I said, ‘What are the symptoms?’ The man proposing it replied: ‘That’s hard to say because the children are very atypical’.”
He paused. “And we were going to include masochistic personality disorder.” He meant battered wives who stayed with their husbands. “But there were some violently opposed feminists who thought it was labelling the victim. We changed the name to self-defeating personality disorder and put it into the appendix.”

Spitzer’s DSM was a huge and instant success, selling over a million copies. It was also, as Ronson points out, “a gold rush for drug companies, which suddenly had 83 new disorders they could invent medications for.”

Serious mistakes
The next edition, the DSM-IV, which came out in 1994, was expanded by Spitzer’s successor, psychiatrist Allen Frances, to include 32 additional mental disorders. But in a phone conversation with Ronson, Frances, who is now a professor emeritus at Duke University, expressed concern that he had made some serious mistakes while working on that project:

“Psychiatric diagnoses are getting closer and closer to the boundary of normal,” [Frances] said.
“Why?” I asked.
“There’s a societal push for conformity in all ways,” he said. “There’s less tolerance of difference. Maybe for some people having a label confers a sense of hope — previously I was laughed at but now I can talk to fellow sufferers on the internet.”
Part of the problem is the pharmaceutical industry. “It’s very easy to set off a false epidemic in psychiatry,” said Frances. “The drug companies have tremendous influence.”
One condition that Frances considers a mistake is childhood bipolar disorder. “Kids with extreme temper tantrums are being called bipolar,” he said. “Childhood bipolar takes the edge of guilt away from parents that maybe they created an oppositional child.”

You’ll can read Ronson’s article at the New Scientist website. Psychotherapist and journalist Gary Greenberg also wrote a fascinating article on this topic last December in Wired. In that article Frances describes his concern that the new DSM, which is scheduled to be released in 2013, will “take psychiatry off a cliff.”

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Comments (3)

  1. Anonymous Submitted by Anonymous on 06/09/2011 - 10:54 am.

    For a better explanation of this check out the three-part BBC production called “The Trap.”

    http://en.wikipedia.org/wiki/The_Trap_%28television_documentary_series%29

    It describes the crisis in psychiatry setup by R.D. Laing’s experiment in the 1960s that led to the “checklist” form of psychiatry. Laing sent out fake patients to mental clinics across the country on the same day, who all presented with one reason why they were mentally ill. After being admitted the “patients” provided NO MORE SYMPTOMS of mental illness. Surprisingly, NONE of the “patients” were released until they admitted they were mentally ill and submitted to “treatment.” This set up an existential crisis for psychiatry and exposed the subjective nature of psychiatric evaluation, leading to the checklist form now prevalent.

    Episode 1: “F*ck you buddy”
    http://video.google.com/videoplay?docid=404227395387111085

    Episode 2: “The lonely robot”
    http://video.google.com/videoplay?docid=-1087742888040457650

    Episode 3: “We will force U 2 be free”
    http://video.google.com/videoplay?docid=-7581348588228662817

    Fascinating and scary. With the advent of the “checklist” other researchers applied it to the general population – finding that the majority of the population, by this definition had a mental illness!

    Further, once the general public saw the checklist they began presenting themselves to psychiatrists, demanding they be provided “cures” for their supposed mental illnesses so they could be normal.

    We see the effects of this today in our culture with the explosion of anti-depressant prescriptions. Are we trying to medicate away common human emotions? Must everyone always be happy?

  2. Submitted by Greg Kapphahn on 06/09/2011 - 01:44 pm.

    The entire field of Psychology both in theory and in practice is, today, roughly analogous to the Medieval field of alchemy.

    The most common views regarding how psychological problems arise are roughly similar to the theories of the “spontaneous generation” of life.

    All you have to do is listen to the various attempts to treat disorders such as phobias, panic disorder, PTSD, etc., to realize that such attempts are not based on any sound, unified theory of the working of the human psyche,

    nor of any sense of what the psyche is trying to accomplish when it creates these unfortunate and difficult responses to certain kinds of traumatic situations

    but rather, represent nothing more nor less than taking shots in the darkness resulting from blind ignorance of the causes and effects of such disorders.

    The blind attempts to try various psychological methodologies are disturbingly akin to the ancient practices of bleeding, blistering, the application of leeches, etc., in the desperate attempt to find SOMETHING that might provide positive results.

    But lacking a unified theory; lacking any deep, theoretical understanding of how the psyche works,…

    how it programs itself to deal with its surroundings in the best ways it can devise to ensure the survival of the individual whose psyche this is,…

    how that self programming, based in an amygdala-centered, self-protective system from our instinctive, preverbal “hunter-gatherer” days (a system which we share with most of the animal kingdom), and not well adapted to the circumstances of our current lives can misfire in comical and tragical ways,…

    and, without that understanding, lacking the ability to de-program inappropriate responses after they’ve been created,…

    only means that psychologists and pharmaceutical companies will continue to provide magical, alchemical treatments that are not often efficacious, but ARE often the source of very generous incomes and profits.

    I hope the day will come when we will do better – the day when each youngster learns as they move through adolescence,

    –how to care for and keep healthy their own psyches,

    –how to heal the wounds they’ve already received,

    –thereby recovering the pieces of their personalities that are already missing,

    –as well as erasing the unfortunate and inappropriate programmed responses they already carry,

    –and–

    –how to deal with the grief that life visits upon them, especially in their adolescent years as they fall in and out of love and deep friendship with those around them,

    and thus as individuals learn to recover and maintain their own psychological health.

    If we can develop the means to accomplish these ends, our society will become healthier, better adjusted, less dysfonic and dysfunctional, and far better able to face and deal effectively with the challenges we will inevitably face in the coming decades.

    Lacking that, the blindness and dysfonic inability to allow information to enter our awareness which does not fit the worldview our dysfunctions force us to wrap so tightly around ourselves,…

    dysfunctions born of the painful experiences we have as we move through life,…

    will prevent many of us from viewing ourselves,

    the problems we face,

    and the world in which we live

    with sufficient objectivity to prevent the destruction of our society, the ecosystems on which we depend, and, likely, even our planet

    (the attachment to wealth as the source of sufficient wish fulfillment to make up for our missing pieces standing in the way of protecting anything BUT wealth and the wealthy, and creating the willingness to sacrifice all else in service of the same).

  3. Submitted by Paul Udstrand on 06/09/2011 - 09:46 pm.

    I’m not saying these complaints aren’t legitimate, but this account of the origin of DSM doesn’t quite ring true. The DSM was an American response to the ICDA-8 (International Statistical Classification of Disease and Disorders). By the time DSM-III came out a committee process had evolved with a process for submitting new diagnosis or modifying existing classifications. Psychiatry is problematic but it’s not as chaotic as presented here.

    There are nevertheless serious issues with classifications, most of the observations here are valid. I’m surprised however that the role of insurance companies has been neglected. One factor driving the checklist diagnostic codes was a demand for standardization in order to get insurance reimbursements.

    Fad epidemics have become rather common but it’s a complex sociological process, and it’s not limited to psychiatry. The Chronic Fatigue-Fibromyalgia epidemic is a medical psychiatric hybrid. The Autism epidemic is yet another example. For some reason the Americans are far more prone to producing these fad and false epidemics. When was in the business Multiple personality-dissociative disorders was the quackery of the day.

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