From LQ 219
The Chronicle of Éric Laurent
The Profound and Enduring Crisis of the DSM Zone
The very serious journal La Recherche, the voice of French scientific laboratories and French-speaking rival of Scientific American, strangely entitles its June 2012 issue: “Mental Illness: The Fraud”. The subtitle reads: Why one European in three is declared mentally ill”. The figures come from a study published in September 2011 in European Neuropsycho- pharmacology. These figures were obtained through a very DSM-style methodology. Academics from Dresden gathered together data from epidemiological enquiries conducted over thirty years in thirty different countries (27 from the EU as well as Switzerland, Iceland and Norway). They took into account 27 mental illnesses in a surprising list that groups together anxiety disorders and insomnia with dementia and ADHD (Attention Deficit Hyperactivity Disorder). This combination immediately bore fruit: 38% of the European population presents a mental illness. Even the WHO, which has a very broad view on mental health, which it defines as a “state of well-being”; sees itself being led to temper such results. Its mental health expert in Brussels, Matt Muijen, comments: “The figure of 38% is an indicator of stress in our society and not only of psychiatric disorders”. This extension-dilution of the clinic by way of the disorder, the syndrome and the item is characteristic of the contemporary epidemiological movement where one doesn’t really know what one is measuring.
Why, however, speak of fraud? La Recherche denounces the willingness of the DSM-5 (see the Chronicle in LQ no. 208) “to continually extend the territory of mental illness”. Sylvie Sargueil, journalist and doctor, supports the theses of Roland Gori and Christopher Lane on the medicalisation of human existence and emotions. She shows the limits of the DSM pseudoscience and draws a conclusion on the fabrication of so-called illnesses by the specific drugs that are proposed by the industry. “This scientific illusion, in effect, reassures a population that is claiming answers and simple solutions, and largely benefits the pharmaceutical industry”. Finally, she warns against “the too frequent recourse to drugs of which the under-evaluated relationship between benefit and risk could lead to a new sanitary scandal”.
In response to this denunciation of the inflation mechanism inherent to the DSM zone, Christan Lajoux, President of the French union for the pharmaceutical industry, denounces those “who are doing business out of the systematic denigration of drug companies” and rejects any direct link between industry and marketing authorization. “To believe that they could be under the influence of the industry is to accord no importance to the eminent experts in these national and European agencies”. Obviously, saying this in the times of the Mediator trial does not have all the credibility one would wish for. The weight of the conflict of interests continues to hover sufficiently for the journal to use the title “fraud”.
Allen Frances, who readers of Lacan Quotidien have come to know (LQ 207) as the Chair of the Task-Force for the DSM-III and the DSM-IV and who unceasingly criticises the Task-Force Chair for the DSM-5, comes to the rescue of the industry in order to condemn all the more the errors of the new Task-Force. “Numerous critics are formulating the abusive hypothesis that the DSM is working for the pharmaceutical industry. This is false. The errors come rather from an intellectual conflict of interests; the experts always over-estimate their preferred domain and want to extend its perimeter, to the point where daily life problems are wrongly qualified as mental illnesses”. The same as he rejects the pernicious influence of Big Pharma as being the cause, Frances continues to think that the foundations of the DSM are healthy. “Psychiatric diagnosis was a professional embarrassment before the publication in 1980 of the DSM-III. Before that, diagnosis was very heavily influenced by psychoanalysis, psychiatrists rarely agreed upon diagnosis and no one really worried about it anyway. The DSM-III raised great interest amongst professionals and the public by specifying the exact criteria for each disorder… The fourth edition of the manual, published in 1994, tried to contain the diagnostic inflation which had followed the preceding edition. It succeeded on the side of adult disorders but did not succeed in anticipating or in controlling the trend of over-diagnosis of autism, attention deficit disorders and bipolar disorders amongst children, which have been produced since then”. He refuses to see that it is the very mechanism of the dismantling of the great frameworks of psychopathology, their reduction to simple items, empirical, clearly observable and without any equivocation, that is in itself inflationist. The empiricism of disorders, proud of its empiricism, went liberated from any hypotheses other than a biological foundation to be discovered one day, is like a common epidemiological currency without governance. Without any “theoretical” discussions on what is a mental illness and what is not, the only debates are about the quantity of items to control. Allen Frances is simply counting on good regulation to solve the DSM zone problems. When he himself directed the DSM Committee of the American Psychiatry Association (APA), he considers that he was doing the job, but that now it no longer works. He therefore wants to take the DSM out of the hands of the APA in order to confide it to an independent agency linked to the Ministry of Health or to the WHO. The miracles expected from regulation by independent agencies constitute the most widespread belief amongst the great health bureaucracies. It is without doubt an illness to add to the catalogue of disorders, an obsession of those in charge. The DSM zone will need more radical measures in order to constitute a reliable and responsible governance, which will be able to take into account the perverse effects of classification and the adverse effects on the population it encompasses.
These perverse effects are particularly noticeable at the intersection with the juridical field. The DSM is not, in effect, merely a classificatory system like any other. It authorises obligatory follow-up care to insurance companies and is used as a directive text for justice in order to determine psychiatric commitment. Because of this juridical function, the criteria that are maintained in order to define the category of “sexual disorders” are particularly numerous. The old stigmatising and out-dated identifications, like “homosexuality”; were removed from the DSM-IV in 1994, and the invention of new categories producing effects of segregation are interesting to follow in detail, which is what Allen Frances is doing, in one of his chronicles for the Huffington Post, which can be found on the website of the US edition. The working group for these themes proposed three new categories to the DSM-5: “hyper sexuality” (Sexual Addiction), “rape” (Paraphilic Coercive Disorder) and the corruption of a minor (Statutory Rape or Hebephilia). These three categories were eventually rejected because they introduced confusion at the limit between mental illness and occasional crime. Their perverted legal consequences, the increased possibility of abusive commitment, were particularly predictable. The USA Supreme Court has, in a recent legislation, reminded us that the distinction to be made between an offense or a crime and an illness must be preserved, otherwise subjects will be sentenced to psychiatric commitment even before committing any criminal sexual act, right from the first offense. Also, the definition of paedophilia as: “Over a period of at least 6 months, an equal or greater sexual arousal from prepubescent or early pubescent children rather than from physically mature persons, as manifested by fantasies, urges, or behaviors” creates the problem of distinguishing between sexual predators who attack no matter who, including children -who are an easier prey- and a genuine fixation. Frances pleads for the substitution of “preferred or obligatory” by “”equal or greater” of which he denounces the false idea of measure, conveyed by a mathematical vocabulary. By adding the “early pubescent” category, up until the age of 14, the DSM-5 thus extends the number of subjects who enter into the category of “paedophile”. The Task-Force leaders deny this, but the medico-legal problem subsists and is of importance. It is not only the retained disorders that are caught up in an inflationary spiral: 100 pathologies in the DSM-I, 400 in the DSM-IV, maybe 500 in the DSM-5. The mnemotechnical rule is simple: One takes the number of the DSM and multiplies it by 100 in order to get an idea of what one is going to find as items. By the mechanical application of definitions, of which the inclusive categories are increasing because we do not see clearly why, without theoretical discussions, we would limit them, more and more subjects will then fall under the scope of medico-legal decisions.
The DSM zone intends to manage the field of mental health according to a system that proposes classifications in the form of hypotheses which incorporate the current state of knowledge recognised by a consensus at the moment when it formulates them. In fact, it is a population management instrument that cannot ignore the consequences of its classificatory authoritarianism going forth masked as false science. It is not the “scientific” hypotheses that the system put in place tests. It tests the effect of segregative standardisation that it produces, and the social tolerance of this effect.
The number of “paraphiliacs” (ex-perverts), on the increase from one DSM to the next, is a particularly sensitive subject, but all discussion on the eventual decrease in the number of autistic subjects testifies to this just as much. The method, in detail, leans upon the logic of the inclusive or exclusive or. In the DSM-IV, the Asperger’s category, in its first criterion A, enumerates four items, of which only two are sufficient in order to be inscribed within this category. In the DSM-5 there are only three items (deficits in social-emotional reciprocity, in the use of non-verbal communicative behaviours, and in relationship development). But it is necessary that the three criteria be present at the same time. The criterion A is completed by the criterion B (Stereotypic Movement Disorder). Yet, it is necessary to cross out one of the two criteria in the DSM-IV and both of them in the DSM-5. The number of possible combinations is mathematically very limited. It has been calculated that with the DSM-IV there were 2688 combinations to obtain a diagnosis of autism. There are no more than six with the DSM-5. There is then a mechanical reduction of the number of cases inscribed in this category. Yet, diagnosis has a legal value in order to give access to programs and care especially reserved for autistic subjects. Doctor Volkmar, of the Yale Child Study Center, (cf. Chronicle in the LQ no. 194) calculated that only 45% of subjects who qualified as autistic in the DSM-IV will be carried over in the DSM-5, in all of the categories of the spectrum. For the specific Asperger’s disorder spectrum, the figures reach 75% of subjects who don’t qualify as such. There is now evidently an acute contradiction between the claims of testing scientific hypotheses on the definition and the nature of autism and the disastrous effects at a medico-legal level of the management of populations. Without the diagnosis of Asperger’s disorder, a child can no longer have access to “inclusive” teaching programs. He will be left outside by sheer classificatory arbitrariness. This movement, brutally deflationist, reminds us of the management of the financial crisis. After a period that was very tolerant towards the inflation of categories admitted in the DSM, between 1994 and 2010, we are hitting the brakes, regardless of the cost for the population. The consequences will be the same as for the population excluded from the work force by brutal deflation. The number of paraphiliacs committed and the number of children excluded from care systems are the two sides of the coin of a scientific authoritarianism which people no longer trust.
On this point, Allen Frances is making a mistake. The DSM system was unhealthy from the very beginning. The current derive of Task-Force leaders, who believe they have reabsorbed psychiatry into neurology and measure the intensity of mental illness “as one measures blood pressure and cholesterol” was already germinating in the initial project. The crisis in the DSM zone will be enduring and profound. Trust no longer seems to be able to be restored without strictly “theoretical” discussions about the dangers of confusing levels between uses and functions of the classificatory language which is spoken in this zone.
Translated by: Frances Coates-Ruet