Why the Newest Psychiatric Diagnostic Bible Will Be a Boon for Big Pharma
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While virtually all psychiatrists today rightfully mock the idea that fleeing slavery could be considered a valid mental illness, it was not until the 1970s that cultural upheaval and political protests persuaded the APA of the invalidity of homosexuality as a mental illness.
And while homosexuality was dropped from the 1980 DSM-3, oppositional defiant disorder (ODD) was added, and ODD is now a popular child and adolescent diagnosis. The symptoms of ODD include “often actively defies or refuses to comply with adult requests or rules” and “often argues with adults.” Is it any more valid to label teenage rebellion and anti-authoritarianism as a mental illness than it is to label runaway slaves as mentally ill?
Even if you believe that oppositional defiant disorder and all the other DSM disorders are in fact valid mental illnesses, for them to be considered scientific, they have to be able to be reliably diagnosed.
In a landmark 1973 study reported in Science, David Rosenhan sought to discover if psychiatry could distinguish between “normals” and those so “psychotic” they needed to be hospitalized. Eight pseudopatients were sent to 12 hospitals, all pretending to have this complaint: hearing empty and hollow voices with no clear content. All pseudopatients were able to fool staff and get hospitalized. More troubling, immediately after admission, the pseudopatients stated the voices had disappeared and they behaved as they normally would but none were immediately released. The length of their hospitalizations ranged from seven to 52 days, with an average of 19 days, each finally discharged diagnosed with “schizophrenia in remission.”
Psychiatry was embarrassed by Rosenhan and other critics and knew if the DSM wasn't fixed, they would continue to be mocked as a science. The 1980 DSM-3 was dramatically altered to have concrete behavioral checklists and formal decision-making rules, which psychiatry hoped would solve its diagnostic reliability problem. But did it?
Herb Kutchins and Stuart A. Kirk are coauthors of two books investigating this claim of “new and improved” reliability of the DSM-3 and DSM-4: The Selling of DSM: Rhetoric of Science in Psychiatry (1992), and Making Us Crazy, DSM: The Psychiatric Bible and the Creation of Mental Disorders (1997).
Kutchins and Kirk detail a major 1992 study done to examine the reliability of the supposedly new and improved DSM-3. This reliability study was conducted at six sites in the United States and one in Germany. Experienced mental health professionals were given extensive training in how to make accurate DSM diagnoses. Following this training, pairs of clinicians interviewed nearly 600 prospective patients. Because of the extensive training, Kutchins and Kirk note, “We would expect that diagnostic agreement would be considerably lower in normal clinical settings.” The results showed that the reliability of the DSM-3—even with this special training—was not superior to the earlier unreliable editions of DSM, and in some cases it was worse. Kutchins and Kirk summarize:
What this study demonstrated was that even when experienced clinicians with special training and supervision are asked to use DSM and make a diagnosis, they frequently disagree, even though the standards for defining agreement are very generous....[For example,] if one of the two therapists....made a diagnosis of Schizoid Personality Disorder and the other therapist selected Avoidant Personality Disorder, the therapists were judged to be in complete agreement of the diagnosis because they both found a personality disorder—even though they disagreed completely on which one!...Mental health clinicians independently interviewing the same person in the community are as likely to agree as disagree that the person has a mental disorder and are as likely to agree as disagree on which of the...DSM disorders is present.