
Review of the DSM-V as a piece of dystopian fiction - carpdiem
http://thenewinquiry.com/essays/book-of-lamentations/
======
davidjohnstone
One of the criticisms being leveled at the DSM-V here is that "normal" is
being negatively defined as the absence of disorder:

> DSM-5 seems to have no definition of happiness other than the absence of
> suffering. The normal individual in this book is tranquilized and bovine-
> eyed, mutely accepting everything in a sometimes painful world without ever
> feeling much in the way of anything about it.

Positive psychology[1] is a branch of psychology that agrees with this
critique, and rather than looking at what goes wrong with people, it looks at
what is right about people. There is a book "Character Strengths and
Virtues"[2] that is aimed at being the positive counterpart to the DSM,
providing a taxonomy of character strengths that have been identified across
different times and cultures.

1\.
[http://en.wikipedia.org/wiki/Positive_psychology](http://en.wikipedia.org/wiki/Positive_psychology)

2\.
[http://en.wikipedia.org/wiki/Character_Strengths_and_Virtues](http://en.wikipedia.org/wiki/Character_Strengths_and_Virtues)

~~~
gioele
What if that characterization is right? Sad but right?

Let's suppose that you feelings are summed up by a score, happiness is just
score 0 and normality being between 0 and a very small negative interval; also
suppose that you cannot go over zero and everything that can happen can
either:

\- decrease that score (you feel bad about something, and that feeling is
related to a certain, possibly temporary, disorder);

\- increase that score, but only up to them maximum value of zero (you feel
bad, but that friend helped you and her jokes are actually funny).

It may be that positive traits and strengths do exists, but it is also
possible that they are limited to being able to only putting you back on track
once you have a problem, not making you more happy or "normal" that you can
possibly be.

~~~
eli_gottlieb
The fact that you have never experienced happiness doesn't mean everyone
else's experiences of it are somehow illusory.

~~~
gioele
Please, I did not wrote that I never experienced happiness, neither that it is
illusory. I am just playing devil's advocate here, the comment started with a
"What if".

The reply from ordinary got my intent right: maybe it is right that happiness
is limited but sadness is not.

I think we could strike a parallel with perfection. Let's think about bowling.
From the DSM-5 point of view, happiness is scoring a "clean game" with all
strikes, i.e. the lack of mistakes. Isn't this the same as "happiness is the
absence of disorders"? You can win a bowling game even if you make few
mistakes, just as you can live a successful life with some small minor
disorders.

As you can see, perfection is very limited and corresponds to a single value:
zero mistakes.

~~~
DanBC
You may be interested in modern concepts of "recovery" \- a patient may not be
conventionally well, but may consider themselves to be 'recovered'.

The team should help that person achieve meaningful recovery, and not just
reach some checklist target of wellness.

------
ACow_Adonis
One is reminded of other fictional works such as American Psycho, by Brett
Easton Ellis. These works are valuable to read not because they are overly
pleasant, but specifically because they are such transparent and horrific
reflections of the inner mental state of the narrator. Such a state is then
projected onto the mind of the reader so effectively that the disgust and
alienation you feel while reading the book is effectively the same disgust and
alienation internalised at all times by the novel's protagonist.

In this the DSM-V is another brilliant piece of fictional writing. A world
where everything is classified, pathologised, and detached from its context,
values, society, and causes. During the entire tome, you are completely
separated from any notion of wellness, love, morality, or healthy human
beings, with everything classified and filed away like a work-bench with
little boxes for every possible failing.

It finally hits you as you feel so disgusted and alienated by the conclusion
of the novel...that this is specifically because the narrator is so alienated
and separated from such realities, and the novel has succeeded perfectly in
its goal. To put you in such a tortured, flawed, and erroneous mindset that
you now understand completely the flawed and erroneous mindset and worldview
of the narrator.

Kudos to the author. Another masterpiece.

------
andrewcooke
i don't understand this. if we assume psychiatry is pretty much in its
infancy, blundering around, then doesn't it make sense to give names to
certain groups of symptoms? because then you can hope to identify patterns.
for example: if 60% of people who do X and feel Y take drug Z then P, Q and R.
isn't that how you start doing science?

i used to be more sympathetic to criticisms of DSM-V, but a couple of months
back i went to see a psychiatrist. who told me he didn't believe in it. fair
enough. but he then diagnosed me with something and prescribed me a drug. when
i asked why, he said i should trust his intuition. without DSM-V or anything
similar there was no structure - nothing i could understand or question. no
logic. just "intuition".

maybe i am missing the point. i can see that "labels" are annoying. but surely
there has to be some systematic approach to symptoms...

[edit: got psychiatry and psychology swapped...]

~~~
kevingadd
I feel like the core criticism here isn't necessarily of structure itself, but
that the type of structure applied when creating the DSM-V is not necessarily
a helpful structure. Grouping things into neat categories and assigning them a
name is useful in the case where structure actually helps patients, but it's
possible to harm them just as much if it goes beyond being a diagnostic tool
and rule of thumb.

I don't think the DSM-V protects against the problem you observed when seeing
a psych, either. I saw one a while back who _did_ believe in the DSM-IV (V
wasn't out at the time) and his approach was still 'it sounds like you fit the
clinical definition of this; I can prescribe you this medication'. The
diagnostic process was, ultimately, 'if this medication helps you probably
have this condition'. I think it's reasonable for that to unnerve you, but
that's really just a symptom of how difficult it is to actually draw concrete,
verifiable conclusions about this stuff.

Many of the conditions described in a tome like the DSM-V as a singular
condition end up having wildly varied symptoms and there end up being
treatments that only work for one subset of people with the condition, while
another treatment only works for another subset. Some people who have a
condition only show a tiny subset of the symptoms. I think it's reasonable to
look at that and ask if some well-meaning people have gone overboard in an
attempt to label and categorize everything.

On a related note, there are many marginalized groups out there that feel
victimized by the authors of tomes like the DSM, because it often classifies
things as 'disorders' that ought not necessarily be a disorder. Those with
unusual sexual orientations, gender identities, or social habits are among the
people who at one time or another have been considered mentally deficient or
mentally ill due to classification. I don't think the people authoring those
classifications necessarily intended to harm those marginalized groups, but
that often IS the result.

~~~
__float
The problem is that psychiatrists aren't really interested in much other than
prescribing medications. Therapy is left to those with degrees in clinical
psychology or social work.

And from what I have experience with--the eating disorder community--many
professionals actually discredit the DSM's categorization (though it has much
improved in the DSM-5) because of its insistence on weight for diagnoses of
anorexia nervosa. But great American insurance often will pay for _nothing_ if
the patient does not have either AN or BN leading to patients being "not sick
enough" for treatment when really, they need it as soon as possible for
recovery to be most successful.

~~~
Apocryphon
It also seems like there's a rivalry between psychiatrists and the
psychologists. I wonder if the latter have their own equivalent text to the
DSM.

------
chaffneue
This article is just purple prose nonsense that takes advantage of their
audience's natural distrust of information that surrounds the human mind (see
the author's reference to multiple benign conditions to discredit the work)
and the author's own hang up about some sad end where "human beings are
individuated, sick, and alone." From pioneers like Freud to the modern
psychoanalysis spectra we have today, I see much of the body of work around
human mental states being about classification/categorization, statistical
aggregation, symptom/diagnosis tracking and vocabulary. The article is more or
less reading a collection of codified medical anomalies and then attributing a
singular, malevolent narrative tone to it instead of just reading it for what
it is: a standardized professional manual with a strict written style and many
collaborators. There's no narration let alone an "unreliable" narrator,
there's minimal subjectivity, there are no actors, there's just some
observational information presented in a standard way. While I'm aware the DSM
has its critics and naff list of non-disorders, I don't believe that
committing to basic research and presenting objective findings is a madness
that itself belongs in the DSM. What if the goal to this manual is altruistic?
What if even one patient benefits from a faster recovery from some mental
malaise because of this manual? I'm inclined to say keep researching!

~~~
mjn
> What if the goal to this manual is altruistic?

That doesn't sound at all out of line with a typical dystopian novel plot. :)

~~~
chaffneue
Haha! good point!

------
fit2rule
The thing about the DSM-V is that it is simultaneously a bible, a dictionary,
a sales catalog, and an industrial reference manual. As a work of literature,
it is the pinnacle of mans' oppression of mankind, categorized, classified.
Any single manner by which one might criticize ones fellows, put them in a
box, and prepare for delivery: DSM-V has it.

------
thucydides
Great piece. Two of my favorite substantive critiques:

1\. "DSM-5 seems to have no definition of happiness other than the absence of
suffering. The normal individual in this book is tranquilized and bovine-
eyed..."

The DSM _does_ turn mental disease into an entirely negative subject: you're
mentally healthy only if you lack any of the listed disorders. The name
"Diagnostic and Statistical Manual" does limit the enterprise contained
within, but practically speaking, the DSM is the Bible for mental health
professionals. It's the document that describes a substantial portion of how
to give care to the mentally sick, and no other document has the same stature.

And yet their Bible contains nothing at all about mental hygiene or positive
practices. Consider how odd that is, how it distorts the mental health
professions. In the realm of "physical" health, medical doctors speak with
unanimity on every medium imaginable about how you should exercise regularly,
eat more fruits and vegetables, etc., to stave off cancer, diabetes, heart
disease, and an array of other ailments. How often do you hear psychiatrists
talk about the importance of working on your empathy and forgiveness skills?
N.B.: doing so will make you happier.

Again, cataloguing symptoms is important, but not all-important. DSM sucks all
the air out of the room and leads those who study the mind to focus
excessively on the neat categorization of symptoms rather than means of
staving off mental illness in the first place or of developing admirable
virtues like courage, self-discipline, and justice.

2\. "On some level we’re to imagine that the American Psychiatric Association
is a body with real powers, that the Diagnostic and Statistical Manual is
something that might actually be used, and that its caricature of our inner
lives could have serious consequences."

We know that the caricatures have serious consequences for millions of people,
which ought to horrify us. I've seen the consequences of this kind of over-
pathologization up close. I've had several criminal clients who've been
seriously affected by faulty prison diagnoses of schizophrenia and bipolar
disorder. These faulty diagnoses led to the prescription of the powerfully
soporific antipsychotic Risperdal, which turned my clients into physically
weak zombies, and, for that reason, into victims of sexual assault. Admittedly
this is an extreme example, but it amply demonstrates the power of the DSM.

~~~
Dylan16807
I understand misdiagnosis of many things, but how do you get misdiagnosed as
schizophrenic?

~~~
thucydides
In the cases I'm thinking of, the patients were labeled paranoid - and
ultimately schizophrenic - chiefly because they were angry and believed others
were out to harm them. (They did not have hallucinations.)

Their "paranoia" may have had something to do with: a. being watched 24 hours
a day, b. being chased around by some sociopathic fellow inmates, c. being
subject to the rule of arbitrary and capricious guards, or perhaps some
combination of the 3.

Also, from the prison's perspective, prison is not a nice place, and
psychiatric labels and medications are useful for keeping inmates in line.

I should note that blacks in the general population are disproportionately
diagnosed with schizophrenia, and it's probably from overdiagnosis due to
race-based misunderstandings. Check out
[http://www.medscape.com/viewarticle/768391](http://www.medscape.com/viewarticle/768391)
and this study
[http://archpsyc.jamanetwork.com/article.aspx?articleid=11510...](http://archpsyc.jamanetwork.com/article.aspx?articleid=1151017),
which confirms on a small scale what I've seen anecdotally in the prison
context

------
bhaumik
If anyone's curious about the changes in DSM-5 (from DSM-IV) here are the
"highlights":

[http://www.dsm5.org/Documents/changes%20from%20dsm-iv-
tr%20t...](http://www.dsm5.org/Documents/changes%20from%20dsm-iv-
tr%20to%20dsm-5.pdf)

Very interesting additions/clarifications.

------
__float
If anyone wants to Google more about the book, it might help to know the
actual book is the "DSM-5". They have discontinued the Roman numeral scheme in
the latest edition (released this year), but some still use the old way.

------
philwelch
What I think a lot of people are missing is that the entire notion of mental
illness is a hack. The basic definition of any mental illness requires that it
interferes with ones ability to live a normal life. Resist the urge to
deconstruct that for a second, I'll come back to it.

Some people have problems that some type of professional help can enable them
to solve. This can range from people who need medication to avoid seeing and
hearing things that aren't there to people who need CBT to get out of a self-
destructive rut to people who need cosmetic surgery to feel like their body
fits their subjective gender. But the United States is full of systems where
you need a diagnosis to do anything--bill insurance, prescribe medication,
declare someone to have a disability so they can collect income without
working. So DSM is a tool for psychologists and psychiatrists to put a code
down on a form so the system will let them help people.

This is why there's a stipulation that it's only a mental illness if it
prevents you from living a normal life. Lots of people have the symptoms of
mental illness, just not to such a degree that it warrants intervention.
Having compulsive rituals is perfectly normal--compulsively washing your hands
until they bleed is not. A good mental health professional will know the
difference and only provide a diagnosis when it's necessary. But ultimately
the DSM isn't a bedrock of abnormal psychology, it's just a tool psychologists
use to make the system let them help people.

~~~
001sky
_The entire notion of mental illness is a hack_ -Job.

That sounds about right.

------
chimeracoder
> “caffeine intoxication disorder.”

As someone who mostly appreciated the DSM-IV (though recognized its
shortcomings), this is my biggest concern with the DSM-V, and why I consider
it to be a step backwards in many ways.

CAVEAT: My understanding of the DSM-V is based on earlier drafts/non-final
editions, so some of these details may be stale, but it appears the general
principles that I object to haven't changed.

The DSM-IV-TR was very specific with its definitions of "substance abuse" and
"substance dependence". My main complaint with the former was the way two of
the criteria were poorly worded. It referred to the amount of legal trouble
and/or risk that the person took to obtain the drug and could, if _very_
broadly (mis-)interpreted, be used to identify any user of any illegal drug as
suffering from "substance abuse" just by definition[0]. This is mostly a
quibble about the wording of one detail, though; I think that these were good
definitions overall and were more helpful than not.

Criticially, the DSM-IV-TR was able to distinguish between casual users of a
drug (be it caffeine, alcohol, marijuana, heroin, etc.) and those who actually
suffered from "addition" (a term I put in scare quotes because it does not
have a medical definition, unlike the words "abuse" and "dependence").

This is a _crucial_ distinction. If you send someone who drinks infrequently
but is not an alcoholic to rehab, you are providing treatment for a disorder
that they do not have. Thus, you wouldn't be surprised (or concerned) to find
their behavior unchanged six months later. You would not consider it a
"relapse" if they continued to drink infrequently.

Unfortunately, the DSM-V turns this on its head, by allowing "fill-in-the-
blank" intoxication disorders. Think of generic classes in Java - they work
the same way. Given the name of any drug, you can provide the corresponding
disorder - in this case, "caffeine intoxication disorder", or "marijuana abuse
syndrome"[1]

The problem with the new wording is that it encourages over-diagnosis of
mental disorders. Instead of requiring a professional to distinguish between
disorders and non-disorders (easy), it lumps all together as disorders, and
requires professionals to distinguish between those which require treatment
and those which don't (hard).

This is not only more difficult medically, but more problematic legally. No
doctor or hospital wants to accept the liability of saying that they saw a
patient _previously diagnosed_ with a disorder and then determined that they
didn't need treatment. This is far worse than simply failing to diagnose a
disorder.

This may seem like a minor point, but it's not. We've been struggling with
issues of overdiagnosis and overtreatment of non-disorders (not just drug-
related) for years; in a very subtle way, the DSM-V further entrenches this
problem.

[0] Incidentally, DSM-V _did_ drop the "legal trouble" criterion.

[1] I forget the exact wording of the latter; this was a while ago and I
believe they changed it.

~~~
DanBC
> The problem with the new wording is that it encourages over-diagnosis of
> mental disorders. Instead of requiring a professional to distinguish between
> disorders and non-disorders (easy), it lumps all together as disorders, and
> requires professionals to distinguish between those which require treatment
> and those which don't (hard).

Don't most of them include wording similar to "... and causes problems in the
patient's day to day life" after a list of diagnostic criteria?

Thus, Bob drinks 15 cups of coffee per day, and it doesn't bother him doesn't
suffer from CID, but Ann who drinks 12 cups of coffee per day, and suffers
significantly if she cannot get coffee (or is perhaps routinely overdosing on
caffeine) does suffer from CID?

------
chattoraj
The NIMH (National Institute of Mental Health) announced a few months ago that
it would be "re-orienting its research away from DSM categories".

Even the guys on the inside don't trust it.

[http://mindhacks.com/2013/05/03/national-institute-of-
mental...](http://mindhacks.com/2013/05/03/national-institute-of-mental-
health-abandoning-the-dsm/)

------
yuubi
"system of repression . . . in which deviance isn’t furiously stamped out . .
. but pathologized instead."

For instance,
[https://en.wikipedia.org/wiki/Sluggishly_progressing_schizop...](https://en.wikipedia.org/wiki/Sluggishly_progressing_schizophrenia)

------
wavesounds
"The word “disorder” occurs so many times that it almost detaches itself from
any real signification, so that the implied existence of an ordered state
against which a disorder can be measured nearly vanishes is almost forgotten.
.... Here all pretensions to objectivity fall apart and the novel’s carefully
warped imitation of scientific categories fades into an examination of petty
viciousness."

Or as Richard Feynman coined it: Cargo Cult Science
[http://en.wikipedia.org/wiki/Cargo_cult_science](http://en.wikipedia.org/wiki/Cargo_cult_science)

Also lets not forget these same people claimed being homosexual was a mental
disorder until 1973!

------
jboynyc
Ian Hacking had a great review of the _DSM-5_ in the _LRB_ earlier this year:
[http://www.lrb.co.uk/v35/n15/ian-hacking/lost-in-the-
forest](http://www.lrb.co.uk/v35/n15/ian-hacking/lost-in-the-forest)

------
tokenadult
I see chimeracoder has already posted a comment here. Maybe I should plunge
in, after looking at the "book review" kindly posted here, to comment on
psychiatric nosology (classification of disorders) in general.

Basis of knowledge disclaimer: I am not a medical doctor, and I have never
attended even an undergraduate-level course in psychology. On the other hand,
I have been reading extensively about psychology for twenty years,[1] mostly
focusing on research on human intelligence and human behavior genetics, and
over the years my participation in online discussion networks gained me an
invitation to participate in the "journal club" (graduate seminar course) on
human behavior genetics at my alma mater. At the behavior genetics seminar, I
have met several researchers who have been trying to clean up psychiatric
nosology and improve the newly released edition of DSM. The researchers I know
locally do NOT like the framework or approach of DSM-5. I'll try to do a
layman's justice to their point of view in what I write below.

We have discussed before here on HN the blog of the director of the National
Institutes of Mental Health, which included a post "Transforming
Diagnosis,"[2] casting considerable doubt on the diagnostic approach taken in
DSM-5, which was published just before DSM-5 itself was published. Most
researchers agree that to develop better understanding of troubles patients
experience, and better approaches to treatment, a lot of mental disorders will
have to be recategorized (including no longer being categorized as disorders)
based on new criteria. That's what the progress of science will look like in
this field.

It's important to remember that Freudianism was still in vogue when I was
young (and constituted most of the higher education in psychology that my
parents received in the early 1950s) and psychology and especially psychiatry
are STILL undoing some of the harm caused to those disciplines by mistaken
ideas from Sigmund Freud. It's easy to tell persuasive stories about what
makes people's minds work, but much harder to test those stories with
evidence.

Neurologists who are interested in science-based improvement of medical
practice have commented[3] on DSM-5, and comments of that kind point the way
forward to improvement of nosology in psychiatry in the future. Therapists may
have to give up their pet "specialities" to recognize the realities of how to
help patients. There will surely still have to be new diagnostic tests and new
drug treatments developed. The DSM-5 didn't do as well as it ought to have to
advance understanding of mental disorders. But its evident faults will prompt
further research, and DSM-5 will eventually be replaced by a new edition, one
I hope will be based on better science.

[1]
[https://en.wikipedia.org/wiki/User:WeijiBaikeBianji/Intellig...](https://en.wikipedia.org/wiki/User:WeijiBaikeBianji/IntelligenceCitations)

[2] [http://www.nimh.nih.gov/about/director/2013/transforming-
dia...](http://www.nimh.nih.gov/about/director/2013/transforming-
diagnosis.shtml)

[3] [http://www.sciencebasedmedicine.org/dsm-5-and-the-fight-
for-...](http://www.sciencebasedmedicine.org/dsm-5-and-the-fight-for-the-
heart-of-psychiatry/)

------
Sagat
I have trouble taking psychology and psychiatry seriously. They are the
softest of the sciences and mostly based on cultural norms anyway. Consider
the fact that homosexuality was labelled a mental disorder in the DSM not long
ago. This is evidence that they make it up as they go along.

~~~
DanBC
> Consider the fact that homosexuality was labelled a mental disorder in the
> DSM not long ago.

It was removed in about 1975. There's plenty of dumb stuff done in many areas
of science 40 years ago.

------
morgante
I feel pretty stupid for taking so long to realize that this is an actual
review of the DSM-5. Up until halfway through, I thought this was indeed a
review of brilliantly executed satire in the form of the DSM. Though that
itself could actually be a pretty interesting literary form...

------
DanBC
> This is one of the major flaws in George Orwells’s 1984: When O’Brien
> laughingly expounds on his vision of “a boot stamping on a human face –
> forever”

Sounds about right. ([http://imgur.com/a/IJnR2](http://imgur.com/a/IJnR2))

