Pierre-Gilles Guéguen
CHRONICLE
BALTIMORE
5am
DSM Madness Through the American Press
The best-seller in June 2013 will not be awarded a literary prize but will instead be the fifth version of the DSM (100 million dollars profit for the DSM-4)
On the other side of the Atlantic, as in Europe, it is giving rise to increasingly acerbic criticisms, not only from those who are opposed to the method but equally from those who reproach it for not being loyal to its objectives of supposedly scientific rigour and "evidence-based medicine". A fundamental tool of health bureaucracies for the regulation of psychiatry, the DSM has largely destroyed the discipline that it is pretending to serve and it would seem that it is not over yet. Very soon, if we believe the American Press, we will all come under psychiatry, which is to say that nobody will be spared from having to take psychotropic drugs. This is the other side of Lacan's version, when he asserts that "everyone is mad, everyone is delusional".
One of the most pertinent of the recent articles, and the funniest, dates from the 14th of May, in the Huffington Post. It is written by Professor Allen Frances (Duke University) who, for a long time, after being a part of the construction team of the DSM, warns against the deviations which, according to him, have diverted the successive versions from the initial project.
He refuses, for example, to endorse the idea put forward by the authors of the Manual according to whom the work would be a series of scientific hypotheses to be continually tested and modified. "Our patients are not laboratory mice!" he declares.
He also criticises the number of purely speculative hypotheses that the DSM contains, many of which will never be tested, which don't respond to clinical practice and are issued from statistical treatments that are far too complex. He next protests against the experts (currently 162) who are supposed to fill in what pure statistical methods are inadequate in treating. The "experts", according to Allen Frances, live in an ivory tower and each has his own pet hobby.
He imputes the critique that is usually made of the new version of the DSM of tending to "medicalise" normality to the unskillfulness of its authors who, for example, sometimes base themselves on works not yet published or still at the hypothetical stage.
The New York Times also published several articles on the subject. They pick up the worries and the widespread criticisms as though Americans were starting to notice the mess due to this megalomaniac project and the dangers that it represents for public health.
Benedict Cary, journalist at the New York Times, points out in an article dated the 8th of May that the panel of experts appointed by the American Psychiatric Association gave up on two items: the "attenuated psychosis syndrome" and the "mixed anxiety-depressive disorder". The first item because it would risk giving grounds to hazardous psychotropic treatments for children and adolescents whilst the second would "psychiatrise" just about anyone in the American population.
He also notes that the APA did not retreat before a new and more restrictive definition of autism, albeit much criticised. Two weeks ago, the APA Congress held in Philadelphia was the occasion of lively debates, notably because the DSM 5 aims to eliminate the "Aspergers" from the category of autism. The debate has been going on since last January.
The expert panel is also trying to establish a better distinction between normal sadness (notably grief) and depressive episodes, but as one could have expected, they entangle themselves in the differences which are not objectifiable in statistical terms.
The NYT chronicler Gary Greenberg also writes on the autism question (his article dated the 14th of May). The criticisms that he develops are more from a sociological viewpoint. He remarks that the restriction of autism diagnosis will have as consequence a decrease in social services support and especially of insurers who will refuse to cover the risks. He rightly notices that the DSM has become a business and that it establishes itself upon the existing solidarity between medicine and the pharmaceutical industry. But we understand less why he feels obliged to attack psychoanalysis in passing, unless it is because he bets on neurosciences and genetic markers.
Let us quote, again on the 14th of May in the New York daily paper, an article devoted to Addiction, written by Ian Urbina. It concerns a proposed extension of the category of addictive disorder which would have great consequences for insurance companies and general public health expenditure (Medicare and Medicaid) which is a very delicate issue for the American tax payer and citizen. For the first time, in effect, gambling addictions will be taken into account, as well as a "non specified addictions" item, which goes to show that Jacques-Alain Miller is right in speaking about generalised addiction.
Between the psychiatrists who consider that the most serious problem concerns untreated psychiatric illnesses and those who militate in favour of a restriction of categories, it is a fierce battle.
Concerning autism, information is contradictory, on the one hand the diagnosis of autism would have already increased considerably (cf; The Chronicle by Eric Laurent: "Autism: Epidemic or the Ordinary State of the Subject" in LQ 194 - nls-messager 490), and on the other hand, the DSM-5 puts into question the qualification of the disorder which would exclude a large part of those who are today diagnosed as autistic. An article written by Casey Schwartz, collaborator of Newsweek and of the Daily Beast (20/01/2012) gives an account of the muddle concerning the putting into question of the nomenclature and the biased functioning of researchers, divided between secret and sensationalism.
As the journalist points out: "The loss of the diagnosis has disastrous consequences for the families who depend upon government assistance… from specialised schools to cognitive therapy and long term assistance (medical and housing)."
The emotion is strong around the DSM object and will stay this way at least until December 2012, when revisions will no longer be accepted.
The great classificatory and management battle is waging on, but where has the subjectivity of the patients gone to?
Translation: Frances Coates-Ruet
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