Psychiatric Diagnosis: Too Little Science, Too Many Conflicts of Interest
Paula J. Caplan, Ph.D.
There is a lot of pain and suffering in the world, and it is tempting to believe that the mental health community knows how to help. It is widely believed, both by mental health professionals and the general population, that if only a person gets the right psychiatric diagnosis, the therapist will know what kind of measures will be the most helpful. Unfortunately, that is not usually the case, and getting a psychiatric diagnosis can often create more problems than it solves, including a lifetime of being labeled, difficulties with obtaining affordable (or any) health insurance (due to now having a pre-existing condition), loss of employment, loss of child custody, the overlooking of physical illnesses and injuries because of everything being attributed to psychological factors, and the loss of the right to make decisions about one’s medical and legal affairs. The creation and use of psychiatric diagnosis, unlike, for instance, psychiatric drugs, is not overseen by any regulatory body, and rarely does anyone raise the question of what role the assignment of a psychiatric label has played in creating problems for individuals.[ii]
The Problematic History
Contrary to popular belief, the enterprise of psychiatric diagnosis is largely unscientific and highly subjective (Caplan, 1995; Caplan & Cosgrove, 2004). Therapists often disagree about which label to assign to a given patient, and there is perhaps surprisingly little definitive research to prove that, “A person with diagnosis X will benefit from and not be harmed by treatment Y.”
These serious limitations have not prevented the authors of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), sometimes known as “the therapist’s Bible,” from making expansive claims about their knowledge and authority and wielding enormous power to decide who will and will not be called mentally ill and what the varieties of alleged mental illness will be. The DSM’s current edition is called DSM-IV-TR, and it was preceded by the original DSM (in 1952), then DSM-II (1968), DSM-III (1980), DSM-III-R (Third Edition Revised) (1987), DSM-IV (1994), and DSM-IV-TR (2000). The DSM-V is currently in preparation and slated for 2013 publication. Each time a new edition appears, the media ask whichever psychiatrist is the lead editor why a new edition was necessary, and like clockwork, each editor replies that it was because the previous edition really wasn’t scientific (Caplan, 1995). And each time a new edition appears, it contains many more categories than does the previous one. For instance, DSM-III-R contained 297 categories, and DSM-IV contained 374 (Caplan, 1995).
I served as an advisor to two of the DSM-IV committees, before resigning due to serious concerns after witnessing how fast and loose they play with the scientific research related to diagnosis (Caplan, 1995). The DSM is widely used, not only in the mental health system, but also in general medical practice, in schools, and in the courts. I have been involved since 1985 in trying to alert both therapists and the public to the manual’s unscientific nature and the dangers that believing in its objectivity poses. Since then, I have watched with interest a national trend toward gradually increasing openness to the idea that psychiatric diagnosis (A)is largely unscientific, (B)is highly subjective and political, and (C)can cause untold harm, ranging from the patients’ lowered self-confidence to loss of custody of children to loss of health insurance (because any psychiatric label can be considered evidence of a pre-existing condition) to loss of the right to make decisions about their medical and legal affairs.
What many do not consider is that psychiatric diagnosis is at the foundation of much of the harm that is done in the mental health system. Without assigning a diagnosis, a therapist is not supposed to choose what treatments to use or even whether or not to suggest treatment. And rarely are patients prescribed psychotropic drugs or told they need psychotherapy unless they get a psychiatric label. This is not to say that psychotherapy and medication is never helpful for anyone but simply that the first step toward the harm that sometimes results from these is assignment of a diagnosis. Futhermore, increasingly people have learned about the connections between drug companies’ concealment of the harm their products can cause and some professionals’ pushing of particular drugs while being paid well by the drug companies. It has been well documented that some of the professionals who help write the DSM are on drug companies’ payrolls (Cosgrove, Krimsky, Vijayraghavan, & Schneider, 2006).
Coming Up Next: DSM-V and Secrecy
With the next edition of the DSM in preparation, and perhaps due to increasing scrutiny and questioning of the process of creating psychiatric categories and an increasing public awareness of the harm that results from their use, the current DSM team has tried to envelop the process of compiling the next edition in a shroud of secrecy (Frances & Spitzer, 2009). Interestingly, the editors of the current and previous editions, Allen Frances and Robert Spitzer, respectively, in a letter to the APA’s Board of Governors described the DSM-V process as characterized by a “rigid fortress mentality” that included asking that those compiling the new edition to sign a statement agreeing to keep confidential the deliberations about it (Frances & Spitzer, 2009). This seems a curious requirement for a group that has often claimed that it bases its decisions strictly on scientific evidence.
In addition to this secrecy, as I learned when asked by Ms. magazine in 2008 to write an article about the future of the category “Premenstrual Dysphoric Disorder” in the DSM-V, those joining DSM-V committees have been told that they must divest themselves of most drug company connections. However, it turns out that this divestment is only temporary, and connections can resume once work on the DSM is finished. Furthermore, as one DSM-V committee chair told me in a telephone interview, this requirement delayed the process of committee formation substantially, because it was difficult to find enough people who were willing to go through with the divestment (Fawcett, personal communication).
Some Problems Already Identified in DSM-V Plans
In keeping with the tradition of DSM editors claiming that, in contrast to previous editions, their edition will be scientific, a proposal apparently receiving serious consideration is the creation of an entirely new system of organizing categories within the DSM-V (Frances & Spitzer, 2009), yet this proposed system is riddled with problems and does not even appear to be a particularly useful – not to mention valid – system for helping people with emotional problems.
In addition, despite the secrecy surrounding the process, additional alarming information about what committee members are considering has already appeared. For instance, a committee was appointed to consider whether “racism” should appear in the DSM-V, a step that would disguise a social evil by making it seem “merely” an individual problem, a mental illness. One danger of such a diagnostic category is that people who commit hate crimes would blame their crimes on alleged mental illnesses and thus avoid criminal punishment (Profit, 2004). This is similar to the category of “rapism,” which was proposed for DSM-III-R and which feminists successfully battled (Caplan, 1995).
In a different realm altogether, one prominent DSM author has proposed that “relational disorder” be added to the manual (Caplan & Profit, 2004). “Relational disorder” would be applied to a couple, neither of whom individually might be considered mentally ill but whose relationship would be considered sick. One of the category’s inventors has suggested that this would provide a terrific opportunity to try out psychotropic drugs. But there are serious ethical problems involved in prescribing drugs to treat people who are not individually diagnosed as mentally ill. It is revealing to picture this scene: Two people sit in a psychiatrist’s office; neither of them is considered mentally ill, though their relationship is; the psychiatrist removes a pill from its bottle…where does the psychiatrist put the pill? Clearly, the ethics, absurdities, and dangers of DSM-V proposals must see daylight and be thoroughly debated as soon as possible.
Even during the preparation of past editions of the manual, changes have been rapidly and often surprisingly made by various DSM subgroups and by those at the top of the hierarchy. For this reason, it would be almost impossible to write a book about concerns related to the DSM-V process. As a result, sponsored and supported by the Association for Women in Psychology (AWP), which has long had as a primary social action objective the understanding of psychiatric diagnosis and prevention of harm that results from it, a task force of academics and clinicians has produced the articles on this website. Most of the articles are about particular diagnostic categories, some are about particular “isms” such as sexism, classism, and racism, and many involve elements of more than one of these. This website is a grassroots project of AWP, and due to limitations of time and personnel, we have only attempted to critique some (though a wide variety) of the 374 different diagnostic categories listed in the current DSM and some that are being considered for inclusion. Furthermore, the secrecy surrounding the DSM-V process makes it impossible to know much the new categories being proposed. So with this website, we offer a sampling of the kinds of problems and concerns that we want to urge professionals and the public alike to watch for as the DSM-V steamroller moves on. In fact, several of the categories addressed on this site have been proposed in major mental health journals and books as DSM-V diagnoses. Unfortunately, many changes in past editions have been made at the last minute and without the public’s knowledge, so that serious problems have become widely known only after the editions were published; those problems have persisted for many years. Indeed, in the case of the widely publicized claim in the early 1970s that “homosexuality” was being removed from the next edition of the manual – a claim that is still generally believed to be true – it emerged that “ego-dystonic homosexuality” actually remained in the next edition after all (Metcalfe & Caplan, 2004). Situations like this make it difficult to think how to protect the public and how to educate the public and professionals about ways to stop the DSM-V authors from causing harm. We hope that this website will provide some resistance to the DSM-V steamroller.
Caplan, P. J. (1995). They say you’re crazy: How the world’s most powerful psychiatrists decide who’s normal. Reading, MA: Addison-Wesley.
Caplan, P. J., & Cosgrove, L. (2004). Bias in psychiatric diagnosis. Lanham, MD: Rowman and Littlefield.
Caplan, P.J., & Profit, W.E. (2004). Some future contenders. In P. J. Caplan & L. Cosgrove (Eds.), Bias in psychiatric diagnosis (pp.249-54). Lanham, MD: Rowman & Littlefield.
Cosgrove, L., Krimsky, S., Vijayraghavan, M. & Schneider, L. (2006). Financial ties between DSM-IV panel members and the pharmaceutical industry. Psychotherapy and Psychosomatics, 75, 154-160.
Fawcett, J. Personal communication.
Metcalfe, W.R., & Caplan, P. J. (2004). Seeking “normal” sexuality on a complex matrix. ”? In P. J. Caplan & L. Cosgrove (Eds.), Bias in psychiatric diagnosis (pp.121-6). Lanham, MD: Rowman & Littlefield.
Profit, W.E. (2004). Should racism be classified as a mental illness? In In P. J. Caplan & L. Cosgrove (Eds.), Bias in psychiatric diagnosis (pp.81-8). Lanham, MD: Rowman & Littlefield.
 The category “Ego Dystonic Homosexuality” appeared in the manual, thus leading to the labeling as mentally ill many people who were not thoroughly comfortable and happy with being homosexual. The fact that in a homophobic society, the lack of total comfort with being homosexual should hardly be construed as proof of mental illness was not acknowledged. Even today, although the words “homosexual,” “lesbian,” “gay,” and “bisexual” do not appear as diagnostic categories in the manual, the category “Sexual Perversion Not Otherwise Specified” does appear, and that is so broadly defined that it could certainly be applied to anyone who is not heterosexual, as long as their particular therapist decides that their sexual orientation is a perversion.
[i] see psychdiagnosis.net for more information about this subject, including stories about a variety of kinds of harm caused directly by psychiatric diagnosis and six different solutions to problems of diagnosis.
[ii] The Association for Women in Psychology, the Society for Menstrual Cycle Research, and the National Women’s Health Network, sponsored by Congresswoman Louise Slaughter and cosponsored by many other organizations, held a Congressional briefing about some of these concerns, and a second briefing was held by the author of this paper (Caplan, Paula J. (2002). You, Too, Can Hold a Congressional Briefing: The SMCR Goes to Washington About “Premenstrual Dysphoric Disorder” and Sarafem. The Society for Menstrual Cycle Research Newsletter, Summer, 1-5. Reprinted in Women’s Health: Readings on Social, Economic, and Political Issues. Fourth Edition. Nancy Worcester & Mariamne Whatley (Eds.). Kendall-Hunt: Dubuque, IA, pp.246-9.) However, no Congressional action to propose hearings or legislation about psychiatric diagnosis has yet resulted from these briefings.