HAVING IT OUT ONCE AND FOR ALL WITH THE DSM
The Mandatory Diagnostic Reference to the DSM is contrary to scientific initiative; Harmful to treatments of the human psyche; Costly for governments; Paralyzing for research and teaching.
The term “psychical or mental suffering” cannot be confined to the traditional definition of “illnesses,” because it may impact anyone and everyone. The World Health Organization has deemed it a major priority, but then initially engaged itself in the struggle against it via a one-sided choice which views the Manual issued by the APA (American Psychiatric Association) as grounded in science. WHO’s restrictive choice bears the generic name of “DSM,” or Diagnostic and Statistical Manual of Mental Disorders, the third version of which stigmatizes conflicts that are important to psychiatric evaluation, and is contemporaneous with the treatment recommendations of the behavioralists and practitioners of CBT. Since its methods are not clearly delineated, they are also contributing to the promotion of an indispensable pharmacological accompaniment.
1. The DSM has no scientific foundation
The DSM’s predecessor the SCND was an empirical compendium published in 1932 for the US Army. In 1948, WHO used it to compile its International Classification of Diseases, which is currently in its 10th version (ICD-10 or CIM-10 in France). The various versions of the DSM have been published beginning in 1952 by the American Psychiatric Association. Whereas DSM-II took into account a psychodynamic approach to psychopathology, the DSM-III, first published in 1980, voided any and all reference to psychoanalysis, in the name of total theoretical neutrality. The result was a descriptive methodology that willingly ignored those psychological concepts out of which an objective, clinical and scientific classification of the major fields of psychopathology might have been developed. The DSM has several axes or sub-sets whose methodologies run entirely counter to the criteria of objectivity of any branch of either the human or natural sciences.
In order for an observation to lay claim to being scientific, it must isolate latent invariances, determining factors that constitute axioms and delineate structures reduced to their component parts. The scientific initiative relies on the observation of facts whilst guarding against prejudices. It is based on the observed facts of experiments and experience, which alone enable us to verify their diagnostic relevance and predictive value. This is the polar opposite of the methodology adopted by the DSM, which has no precedent in any science whatsoever, other than perhaps the early encyclopedic classifications of the likes of Linné, Buffon and others, who classed the species according to their distinctive characteristics, prior to shifting towards comparative classifications designed to highlight the shared traits each such species possessed.
The Introduction to the DSM ideologically declares it to be atheoretical. But is this possible in research? The DSM itself demonstrates it is not, because just as soon as even one list of manifest “disorders” is compiled without factoring in the psychical structures in which they are inscribed; and just as soon as these “disorders” are detached from the subjective circumstances of their eruption, the hypothesis that an organic cause is at work immediately imposes itself. And yet this reductionist conception of a “machine-man” has to this day never been corroborated by any experimental proof, including those of the most renowned neuroscientists.
Contrary to the DSM, the most recent scientific advances in the domain of neuroplasticity and epigenesis have shown that we cannot make an opposition between psychic/mental and organic causalities, since the former influences the construction of the latter, thereby subverting its predictive value: the same brain is never employed twice. Thus by suppressing psychic causality, the DSM imposes organic causality in the balance. This choice is all the more anti-scientific in that it proscribes other reference texts even as its usage is imposed upon practitioners for the purposes of diagnostic coding. As Karl Popper has demonstrated however, the consequence of being unable to refute a point of view is its removal from the scientific domain. No matter how scientific versions III and IV of the DSM may claim to be, their methodology is absolutely not scientific.
The second anti-scientific characteristic of the DSM’s methodology is revealed by the fact that it groups together statistics that are not about patients, but rather the opinions of a sampling of psychiatrists. These are not clinical observations, but rather the summing of opinions which sometimes have even been gathered in arbitrary fashion. This method, democratic in appearance, is nowhere to be found in the history of the sciences. A vote can never serve as proof, and yet the DSM’s nomenclature has been placed on the chopping block of opinion, as witnessed in its legitimization by the term “consensus,” which may be a popularity indicator, but in no instance confers scientific validity.
The fact that these primary characteristics of the DSM are non-scientific does not prevent us from finding epidemiological value in it as part of a reason-based governing process. If we intend to make use of it for this purpose however, practitioners should not be required to refer to it in making diagnoses and prognoses, an obligation which furthermore runs counter to the ethics of medicine and the mental health professions.
2. A methodology with zero clinical validity
The DSM’s repertories of “disorders” and “dysfunctions” only furnish psychical or mental suffering with surface level clichés. There is no branch of medicine in which a practitioner would diagnose an illness founded solely on the manifest expression of a symptom. Since information provided by regular patterns (invariances) are avoided on principle, surface descriptions are multiplied: this so-called “Evidence Based Medicine,” which claims to favor evidence in pursuit of greater effectiveness, reveals its true goal by limiting clinical explorations to the most superficial evidence, and by mixing up elements of otherwise heterogeneous orders (particularly the clinical and moral): take for example the comment by Dr. Roger Misès about “behavioral problems, “ which he refers to as “incivility” cum illness.
The result is an inflation of “disorders,” an inflation which corroborates the aforementioned absence of scientificity, since an authentic scientific initiative enables us to delimit a large variety of manifestations to a few clinical types whose number has been reduced. From the 106 pathologies listed in the version from 1952, the DSM’s current version now identifies 410 “disorders.” DSM-V, which is currently being developed, should log at least twenty-some additional categories. In terms of mental pathology, it has constructed various “false positives” whose sole beneficiaries would appear to be the pharmaceutical companies. What is more, this inflation is nurturing the birth of catchall concepts that justify sometimes dangerous and stigmatizing treatments for children.
In prior versions of the DSM, a clinical category as constant as hysteria, witnessed to by the experience of Antiquity even, was deleted. In similar fashion, neurosis has no longer been included since 1980, although homosexuality would have to wait until 1987 to no longer be viewed as a mental illness; the date when, paradoxically enough, sexuality itself lost its status…All this leaves us with the idea that these statistics refer more to American culture, its norms and its fashions, even as the DSM’s psychopathological categories reveal their international ambitions. Indeed the WHO plans to impose the application of the ICD on a global scale within the next few years.
As for the planned DSM-V of the future, new and entirely dimensional categories are being invented, based on the amplitude of the manifestations it deems pathological, such as “hypersexuality disorder” and “coercive paraphilia disorder.” Even more troubling still, the addition of “predictive factors” as portents of “future disorders.” Each of us will thus potentially be ill and thus candidates for preventative treatment. The pinnacle of this vertigo-inducing inflation is no doubt reached with the invention of “risk syndromes” such as “psychotic risk syndrome,” which goes from prevention to prediction by calling for the systematic prescription of psychotropic medications at non-negligible doses for adolescents who are deemed atypical. And all this despite the fact that no field test has even shown its usefulness. Such an expansion of pathology might even be deemed against Human Rights.
3. The DSM is Hazardous to Your Health
Once a sufficiently broad catalogue of criteria is achieved, psychiatrists will soon no longer be necessary. Nor will doctors or even nurses. Sole the pharmacist will be able to directly distribute psychotropic medications. If this were in fact the policy governments were heading toward, how effective would it be? A DSM diagnosis groups together behavioral manifestations without the in-field depth afforded by a more encompassing psychopathological structure, in direct contradiction to psychiatric clinical experience. Each behavior is made to correspond to a checkbox, and becomes nothing more than the sign of a “disorder” erected into an innate pathological entity, to which is added notions such as “patient difficult” or “non-compliant with treatment.”
Finally, some DSM categories (coded F20-F31 for example) are seemingly going to be used to transfer administrative qualification towards medical and social work practitioners, thereby stripping public and private psychiatry of the meat and potatoes of its purpose. Already, in some public hospitals and clinics in the Paris region for example, and again in the name of “objectivity,” the use of “checklists” as early as the initial interview with patients has overturned clinical semiology, deemed “subjective,” along with the psychodynamic approach to working with symptoms.
The DSM has deleted any and all reference to causality stemming from the psyche and/or patient history, while nevertheless leaving room for traumatic events in the patient’s life and case history: everything is programmed, as if the entire human condition could simply be medicalized. Relational therapy, or even one that simply includes talking, have been invalidated as therapeutic tools to such an extent that patients who feel an urgent need to divulge themselves are at risk of opting for non-scientific, meaning non-professionalized, therapies, all with the unwitting support of the public authorities.
On the basis of these checklists, most patients are medicated abusively or for too long. Since one and the same symptom may be claimed to play a role in different mental structures or axes that do not call for the same therapeutic conduct, and since that symptom may be effectively snuffed out through pharmacological treatment, the underlying cause of the psychical suffering in question becomes unrecognizable, and the patient is rendered incurable, despite very heavy doses of medication.
To the extent they relieve effects and not their causes, prescriptions become auto-renewable and may augment dangerously, even to the point of dependency or addiction. When a particular treatment protocol fails, instead of placing the entire approach into question a new category is believed to have been created. In this way therapeutic approaches using medication, often useful at first, end up producing counterproductive results. This is all the more true in that the long-term unwanted side effects of recent medications remain unknown, and preliminary risk/benefit studies are often subjected to caveats.
Today, this vicious circle is being initiated as early as childhood. Currently child psychiatrists, the majority of which are in psychoanalytic training programs as well, who want to take preventative action for children and adolescents seek to collaborate with pediatricians and educators to detect the early warnings signs of mental health issues, in order to avoid a latent problem from evolving and definitively forming into a psychosis, severe neurosis or other permanent inadaptation. However the DSM-V transforms this prevention into a therapeutic anticipation: we are not to provide care for what the child is actually suffering from now, but rather for a disorder which may, one day, arise in him or her. This “predictive measure” risks enclosing a child in a lifelong diagnostic category, replete with medications for psychopathologies that have never even actually appeared. To the contrary, when the signs of mental suffering are seen, this treatment avoids the fixation of a pathology.
4. The DSM Orients Education and Training Towards One Mode of Practice
The success of the DSM is not a result of its positive reception from practitioners. Just the opposite, it has been imposed on them from the outside. Its expansion is due, first and foremost, to insurance companies and pressure groups that demanded reference codes for their reimbursements in the US and some European countries. The pharmaceutical companies are also behind the mapping grids used to match up DSM categories and the administration of medications. These various lobbies have had sufficient power to drive ever greater numbers of universities to make the DSM the core of their curriculums, thereby furthering the financial and ideological interests of those who benefit from such classificatory schemes.
Future clinicians are being formatted in total ignorance of traditional clinical experiences. The proto-organicist is taught to eliminate all points of view that came before, to make a break that nevertheless does not ground the appearance of any new paradigm. Up until the end of the 1970s a relative degree of unity prevailed in the domain of psychopathology. European psychiatric clinical experience was enriched by the contributions of psychology and psychoanalysis. These interdisciplinary exchanges were only subject to partition beginning in 1980: a partition it should be added that was unfounded, insofar as the object of psychopathology remained the same in that year.
Today, the majority of the curriculum of psychiatry is based on the DSM and pharmacology. In France only the allied health schools for psychology retain a diversity of viewpoints. But for how much longer? Their relative diversity is not in fact equitable, because per French regulations psychologists are not permitted to make therapeutic decisions (regarding diagnosis, treatment plans, etc.). Furthermore, this division between psychologists and psychiatrists is feeding an “ideological war” that is not helpful for the patients and budgets who are paying its price.
Not only medical teaching and curriculums are being sucked into the DMS’s unified format: more and more, the essential components of post-graduate teaching is being undertaken by pharmaceutical laboratories, meaning their training is fueling an expansion in prescriptions for medications, and any other orientation for research is proscribed.
Finally, hidden and never democratically debated lobbying efforts have led to the adoption of a mandate that researchers publish articles in line with this same research orientation, in qualified, often British and North American journals, if they want to receive offers for university posts. The CFTMEA (France’s classification for mental disorders in children) has thus hobbled the careers of some scholars by preventing them from publishing in these British and North American journals due to the “lack of a shared vocabulary.”
5. The Inflexible Orientation of the DSM is Costly for Governments
WHO’s adoption of the DSM is having ever greater repercussions on state healthcare systems, and is requiring the adoption of onerous measures. At all levels of the mental health system, the DSM has become an accounting tool for budgets administrated by managers who are organizing healthcare on the basis of financial constraints. Real healthcare problems are remaining therefore unaddressed and in the end wind up being more costly. Commissions unknown to the public are adopting measures using this as a basis point, and since the DSM is their point of reference they are favoring pharmacological (and even surgical) treatments that are impoverishing if not outright dismantling the psychiatric structures designed to serve as a conduit between the hospital and its beyond.
The DSM has become the pharmaceutical industry’s Trojan Horse within the walls of the daily practice of medicine, and in particular in those of the General Practitioners, who are prescribing 80% of the psychotropic drugs in question. These therapeutic trends are levying an enormous financial burden on governments and social programs such as Medicare, Medicaid and Social Security (which administers Medicare in France). The cost is not only the underlying transfer of profits to the pharmaceutical industry. There are also “medico-economic” uses of the DSM whereby, depending on the DSM coding used, “patient rates” and “treatment intensities” are spelled-out in advance in ways that impose limitations on therapeutic options.
To obtain an idea of the size of the costs generated by DSM-based diagnoses we might examine the differences in child psychiatry prescription rates in countries that comply with the manual and those where other points of view are still in the majority: in France, nearly 20,000 children take Ritalin every year, far fewer than the 55,000 British children, and nowhere near the 3 million Canadians and seven million children in the US. The close ties based on financial interest between the pharmaceutical industry and the experts compiling the DSM-IV are hardly surprising and have been revealed many times, especially considering how extremely profitable the market for psychotropic medications is. In 2004 in the US, anti-depressants generated 20.3 billion dollars in profits, and anti-hallucinogens generated 14.4 billion. Certain clinical categories are being tailored as closely as possible to the indications of new drug molecules, a portent of a dawning pharmacological classification system that may be customized to fit the needs of marketing departments. Such coincidences between clinical categories and drug effects are tailor-made to favor mass drug therapy.
Although from the financial point of view treatments that privilege intersubjective relationships may at first appear more expense in terms of infrastructure and qualified personnel, in the long term they are more economical, and also respect the human dimension to be included in the giving of care.
It is possible to put an end to the damaging hegemony of this nomenclature.
In 2001, WHO and the WPA (World Psychiatric Association) held a symposium in London on international classification standards. The difficulties revealed during the debates lead the WHO to decree a moratorium on the revisions to DSM-V and ICD-10 until this year. In reality, the waltz of DSM revisions was being conducted at the sole initiative of the American Psychiatric Association and not by practitioners, as initially foreseen. In the meantime, the consequences of the usage of the DSM are revealed on a daily basis. They are as easy to spot in reports by INSERM, (France’s national research regulatory organization), as they are in legislative decisions impacting mental health. On a deeper level, these nefarious consequences may also be identified in their effects on patient isolation and internment policies, which are gravely harming not only the provision of healthcare to humans, including children of very young ages, but the legitimacy of political governance as such. For example the DSM is now used in court proceedings, where its apparent objectivity is all the more dangerous in that it cloaks itself with the discourse of “science.”
Experience has shown however that actors in the healthcare field can roll back the effects of the DSM ideology. For example, a petition entitled “No Zero Tolerance Misconduct Policy for Children Three Years and Up,” (against a French government policy to begin special treatment and isolation measures for children showing early warning signs of “delinquency,”), which was signed by more than 200,000 people in the wake of a study by INSERM on “behavioral disorders,” led to INSERM’s having to relativize some of its research which had previously been forwarded as scientific. Similarly, the “Call for Calls” campaign managed to capitalize on critiques of reigning nomenclature in healthcare, education and research by grouping them together into a “Save our Clinics” initiative. Other responses to the current threat we face have already happened and are currently underway, such as the “The Collective of 39 Against the Mandatory Overnight Internment of Psychotic Patients” recently managed to reunite more than 1,000 people in Villejuif, France (October 2010).
In 2001 in Montpellier, France, a convening of an “Estates General of Psychiatry” made it possible for a large share of the psychiatric professional organizations to take a position against the DSM-IV, joined by virtually 100% of the psychoanalytic institutes as well as the SIUERRPP (inter-European academic consortium on psychoanalysis and psychopathology), which represents and brings together the vast majority of faculty-researchers-practitioners in the field of clinical psychopathology. The majority of French psychoanalytic institutes signed on this occasion a declaration in which they proposed to “work together with professionals in psychiatry on the construction of a psychopathology reference work that is more in agreement with the clinical reality of patients.” As this declaration itself notes, the DSM is engendering a mode of clinical practice that “confounds the patient with the illness. It is a mode of clinical practice that does not factor in the subjectivity of the unconscious or psychical conflict, both of which are concepts designed to demonstrate that our patients have a history and a relational universe that are patently at work in the clinical picture they present.”
We want to work together positively towards a clinical practice that includes human subjectivity.
The number of signatories to this Manifesto constitutes a degree of expertise every bit as decisive as the APA’s statistics. We believe this clinical nomenclature has been imposed using non-research based methods and that it impedes the normal course of scientific sharing and exchange.
1. We believe that clinicians who are attentive to the psychical and/or mental aspect of human suffering and its treatment are finding themselves today confronted with the added problem of having to contend with the imposition of this one-sided, falsely consensual mode of thinking, as well as with its dangerous utilization in the taking of therapeutic, managerial and administrative decisions. In our view the dangerous and costly inflation of pathological categories must be halted. The chain of clinical support that had been carefully constructed over several centuries of collaboration and exchange between psychiatry, psychology, psychoanalysis and anthropology must be restored.
2. Pressure by administrative bodies and authorities on clinicians must immediately cease: pressures which, under cover of budgetary or accounting requirements, are dictating their therapeutic conduct. Is it not time, for example, to take a stand against the so-called VAP initiative seeking to assign valuations to various psychiatric treatment modalities, and to even imagine refusing to provide codes (or else to always code F99 – Other)?
3. A scientific methodology that respects contradictory viewpoints must be reestablished and instituted. We demand in this respect the reestablishment of a plurality of doctrinal viewpoints in curriculums, as well as liberation from the straightjacket of the DSM on research and qualifying journals. The obligation to use “DSM vocabulary,” to speak a single psychiatric language, must not be used as a criteria for acceptance to publish in international journals. Only the object of the research in question and its purpose may be taken into account. A plurality of conceptual reference texts must be respected and furthered. The DSM is not and may not be made the mandatory and exclusive reference text as a tool for standardizing the clinical practices and conducts of the population. It is vital that we achieve transparency in the designation of experts for decisionmaking commissions in this domain.
4. Classificatory schemes other than the DSM already exist. Their existence must be validated and taught. Some have already been proven effective with children and adolescents, such as the CFTMEA (French classification of mental disorders in children and adolescents), which has been used repeatedly in epidemiological studies, and which furthermore includes a table of correspondences with the CIM-10. On a parallel track, a classificatory scheme tailored to clinical experience will be debated and its foundations mapped out.
5. It is vital that we maintain sharp distinctions between specific challenges and needs that have currently become intermixed. Which criteria become useful changes depending on whether the domain is administrative, involving epidemiological and public health studies, clinical and therapeutic practice, and research or teaching.
This return to scientific development and initiative does not signify a return to the past. It requires that we absorb and subsume the contributions of pharmacology and the neurosciences, which themselves enable us to better compartmentalize organic mediations and psychic or mental causality. This is also not a call for a return to classical nosology, which must itself begin to take into consideration a comparative analysis of clinical experiences using contributions from other cultures; as well as the fact that we must gauge changes in lifestyles that are causing symptomatic manifestations to appear that were less evident in the past. Research such as this will enable us to found clinical criteria with universal validity.
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