Psychiatric Deviance: Diagnostic Labeling
Part 2. The Construction of DSM-III and DSM-IIIR

The Medicalization of Deviance

In Rosenhan's study of the labeling process in "insane places," the pseudopatients observed a number of examples of how ordinary activities, such as taking notes, were interpreted by staff members as symptoms of psychiatric disorder ("patient engages in writing behavior"). These examples illustrate on a small scale the more general societal process of the medicalization of deviance. A number of sociologists and other observers have noted that various forms of deviant behavior as well as other problems of everyday life are increasingly being defined as medical or psychiatric disorders in the U.S. and elsewhere. This historical tendency is also illustrated by the growing influence of a medicalized conception of deviant drinking as "alcoholism" throughout the 20th century or by the dramatic increase in the diagnostic labeling and medication of school children. In some school districts, as much as a third of the children have been diagnosed with ADHD (attention deficit-hyperactivity disorder) or similar conditions and placed on stimulant drugs. However, the continuing movement to medicalize deviance is no where more apparent than in the growth in the size and scope of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, which is commonly referred to as the DSM. From its origin in 1952 as a brief volume of less than 90 pages of psychiatric diagnoses, the most recent edition, the DSM-IV-TR, has grown ten-fold to over 900 pages! This "Big Book of Labels" includes everything from schizophrenia and other psychotic disorders to anxiety or sleeplessness induced by coffee consumption. A comprehensive list of diagnostic labels from the DSM-IV-TR is available at http://www.behavenet.com/capsules/disorders/dsm4TRclassification.htm.

The material that follows is from a recent article in The New Yorker magazine, which tells the story of how committees of clinicians and researchers led by a psychiatrist, Robert Spitzer, constructed the third edition of the DSM and a substantial revision known as the DSM-IIIR. As you will see, the expansion of the medicalization of deviance in these two editions of the DSM often appears to have been driven less by advances in psychiatric knowledge than by the personal vision of Spitzer, the social dynamics of committees, and the economic demands of the medical and insurance industries.

The Dictionary of Disorder:
How one man revolutionized psychiatry

by ALIX SPIEGEL

The following material is excerpted from:


January 3, 2005, pp. 56-63

Click here (pdf) to read full article.

 
Robert Spitzer isn’t widely known outside the field of mental health, but he is, without question, one of the most influential psychiatrists of the twentieth century. It was Spitzer who took the Diagnostic and Statistical Manual of Mental Disorders—the official listing of all mental diseases recognized by the American Psychiatric Association (A.P.A.)—and established it as a scientific instrument of enormous power. Because insurance companies now require a DSM diagnosis for reimbursement, the manual is mandatory for any mental-health professional seeking compensation. It’s also used by the court system to help determine insanity, by social-services agencies, schools, prisons, governments, and, occasionally, as a plot device on “The Sopranos.” This magnitude of cultural authority, however, is a relatively recent phenomenon. Although the DSM was first published in 1952 and a second edition (DSM-II) came out in 1968, early versions of the document were largely ignored. Spitzer began work on the third version (DSM-III) in 1974, when the manual was a spiral-bound paperback of a hundred and fifty pages. It provided cursory descriptions of about a hundred mental disorders, and was sold primarily to large state mental institutions, for three dollars and fifty cents. Under Spitzer’s direction—which lasted through the DSM-III, published in 1980, and the DSM-IIIR (“R” for “revision”), published in 1987—both the girth of the DSM and its stature substantially increased. It is now nine hundred pages, defines close to three hundred mental illnesses, and sells hundreds of thousands of copies, at eighty-three dollars each. But a mere description of the physical evolution of the DSM doesn’t fully capture what Spitzer was able to accomplish. In the course of defining more than a hundred mental diseases, he not only revolutionized the practice of psychiatry but also gave people all over the United States a new language with which to interpret their daily experiences and...their emotional lives....

Spitzer had no particular interest in psychiatric diagnosis, but in 1966 he happened to share a lunch table in the Columbia cafeteria with the chairman of the DSM-II task force. The two struck up a conversation, got along well, and by the end of the meal Spitzer had been offered the job of note-taker on the DSM-II committee. He accepted it, and served ably. He was soon promoted, and when gay activists began to protest the designation of homosexuality as a pathology Spitzer brokered a compromise that eventually resulted in the removal of homosexuality from the DSM. Given the acrimony surrounding the subject, this was an impressive feat of nosological diplomacy, and in the early seventies, when another revision of the DSM came due, Spitzer was asked to be the chairman of the task force....

Given unlimited administrative control, he established twenty-five committees whose task it would be to come up with detailed descriptions of mental disorders, and selected a group of psychiatrists who saw themselves primarily as scientists to sit on those committees. These men and women came to be known in the halls of Columbia as DOPS, for “data-oriented people.” They were deeply skeptical of psychiatry’s unquestioning embrace of Freud. “Rather than just appealing to authority, the authority of Freud, the appeal was: Are there studies? What evidence is there?” Spitzer says. “The people I appointed had all made a commitment to be guided by data.” Like Spitzer, Jean Endicott, one of the original members of the DSM-III task force, felt frustrated with the rigid dogmatism of psychoanalysis. She says, “For us dops, it was like, Come on—let’s get out of the nineteenth century! Let’s move into the twentieth, maybe the twenty-first, and apply what we’ve learned.”

There was just one problem with this utopian vision of better psychiatry through science: the “science” hadn’t yet been done. “There was very little systematic research, and much of the research that existed was really a hodgepodge—scattered, inconsistent, and ambiguous,” Theodore Millon, one of the members of the DSM-III task force, says. “I think the majority of us recognized that the amount of good, solid science upon which we were making our decisions was pretty modest.” Members of the various committees would regularly meet and attempt to come up with more specific and comprehensive descriptions of mental disorders. David Shaffer, a British psychiatrist who worked on the DSM-III and the DSM-IIIR, told me that the sessions were often chaotic. “There would be these meetings of the so-called experts or advisers, and people would be standing and sitting and moving around,” he said. “People would talk on top of each other. But Bob would be too busy typing notes to chair the meeting in an orderly way.” One participant said that the haphazardness of the meetings he attended could be “disquieting.” He went on, “Suddenly, these things would happen and there didn’t seem to be much basis for it except that someone just decided all of a sudden to run with it.” Allen Frances agrees that the loudest voices usually won out. Both he and Shaffer say, however, that the process designed by Spitzer was generally sound. “There was not another way of doing it, no extensive literature that one could turn to,” Frances says. According to him, after the meetings Spitzer would retreat to his office to make sense of the information he’d collected. “The way it worked was that after a period of erosion, with different opinions being condensed in his mind, a list of criteria would come up,” Frances says. “It would usually be some combination of the accepted wisdom of the group, as interpreted by Bob, with a little added weight to the people he respected most, and a little bit to whoever got there last.”

Because there are very few records of the process, it’s hard to pin down exactly how Spitzer and his staff determined which mental disorders to include in the new manual and which to reject. Spitzer seems to have made many of the final decisions with minimal consultation. “He must have had some internal criteria,” Shaffer says. “But I don’t always know what they were.” One afternoon in his office at Columbia, I asked Spitzer what factors would lead him to add a new disease. “How logical it was,” he said, vaguely. “Whether it fit in. The main thing was that it had to make sense. It had to be logical.” He went on, “For most of the categories, it was just the best thinking of people who seemed to have expertise in the area”....

The DSM-III and the DSM-IIIR together sold more than a million copies. Sales of the DSM-IV (1994) also exceeded a million, and the DSM-IV TR (for “text revision”), the most recent iteration of the DSM, has sold four hundred and twenty thousand copies since its publication, in 2000. Its success continues to grow. Today, there are forty DSM-related products available on the Web site of the American Psychiatric Association.

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