John Livesley, emeritus professor of psychiatry at the University of British Columbia, resigned last summer from the Personality and Personality Disorders Work Group of DSM-5 because he was so appalled by the vagueness, inconsistency and “stunning disregard for evidence” that characterized the process of revising diagnoses of personality. (This is the category that includes sociopaths, narcissists and borderline personality, among others.)
“Alas,” he says, “the DSM is influenced by a large number of factors besides scientific evidence.”
Often, those making the decisions are established figures who are settled in their thinking and resist new ideas, not unlike the old psychoanalysts who were unable to incorporate fresh insights questioning female “penis envy,” or whatever begged for a double-take. They are Ivory Tower figures, too. “Many members of the Work Group,” Dr. Livesley points out, “do not see patients regularly and some have never or only rarely seen patients.”
It is easier to ponder how many angels can dance on the head of a pin when no angel is present to argue.
Here is another concern with the trajectory of the DSM: It has been steadily undermining the importance and credibility of the major mental illnesses, which deserve most of medicine’s attention and resources. “The DSM evolved as a language of communication between clinicians and researchers,” says psychiatrist David Goldbloom, current chair of the Mental Health Commission of Canada, “so that they could be talking about the same observed phenomena when they summarized it with a diagnostic label. I don’t think it was conceived of as a biblical embodiment of absolute diagnostic truth of disease, even if people use/see/fear it that way. There are no biological markers for any psychiatric disorder presently. Genes code for proteins, not for the DSM. While I understand the heat about DSM-5 and share the concern about its potential to medicalize normative human experience … it is unlikely to change the severity of who I see as a clinician. The concern about DSM-5 seems to be at its margins.”
At its margins, which is where many of us – the bereaved, the heartbroken, the flat-broke – reside, this is about what story we want to tell ourselves about who we are. Our narratives, as we live and ascribe meaning to them, are richer and more nuanced than what is laid out in a set of behavioural criteria, or a shrinking number of physical symptoms. This is why the APA has received such vigorous push-back on the current revisions. Unwittingly, the DSM-5 revisionists are contributing to an impoverishment of meaning, and it may be that the need to generate meaning, to make sense of experience, is more important to our wellness – at these margins – than drugs.
“Psychiatry has entered the new era of the DSM, yet none of the many evaluations carried out in its name in the U.S. and Europe has shown significant or lasting improvement in the mental health of their citizens,” wrote Patrick Landman, the French psychiatrist who is part of a movement to boycott the new edition. “To cite just one of many possible examples, between 2000 and 2009, the consumption of antidepressants in the OECD countries increased by an average of 60 per cent. No study has shown a decline in the prevalence of depression. Quite the contrary: The suicide rate in Iceland, a country that consumes the highest amount of antidepressants per capita, has been constant for the past 10 years.”
Awkward data, that. Unfortunately, it’s also quantifiable.
Editor's Note: An earlier version of this article on psychology incorrectly described Aaron Beck as a psychologist. Dr. Beck, the inventor of cognitive-behavioural therapy is a psychiatrist.