The Diagnostic and Statistical Manual of Mental Disorders (DSM), the official list of mental illnesses recognised by the American Psychiatric Association (APA) has indeed come a long way. Four previous editions were published, with the fifth edition, DSM V, scheduled to be published in May 2013. Without a shadow of doubt, the DSM V publication is an eagerly anticipated event by the psychiatry community. Since its first publication in 1952, the processes and behind-the-scenes developments surrounding the DSMs are not without their fair share of dramas and controversies. Therefore, this necessitates the description of background and developments within the discipline of psychiatry concurrent with the publication of various DSM editions.
During the 19th and for most part of the 20th century, much of psychiatry was dominated by the field of psychoanalysis. Popularised by Sigmund Freud, psychoanalysts believe that the mind has two parts, the conscious and unconscious. The conscious mind is what the person is aware of, i.e. his thoughts, perceptions, fantasies, feelings, etc. According to Freud, there is another layer below the conscious mind, the preconscious mind. Better known as the “available memory”, it serves to bring into consciousness what we are not currently aware of. However, the largest part of the mind is occupied by the unconscious. Intrinsic to it are elements which are not available to our current awareness. Freud thought of the unconscious as the source of our motivations, be it desires for food or sex, scientific or artistic motives, and others.
The psychoanalysts are at odds with descriptive psychiatry adherents. The field of descriptive psychiatry attempts to focus on observable behaviours, symptoms and conditions, e.g. speech, body language, all of which can be demonstrated empirically, rather than the underlying processes that led to the aforementioned observations. The psychoanalysts viewed descriptive psychistry as “narrow, bloodless and without real significance”. To the psychoanalysts, demonstrated symptoms are seen as unimportant and considered superficial, while the real deal is internal conflicts that lie within the individual. Robert Spitzer, an influential psychiatrist worldwide and then the chair of the task force responsible for the third edition of APA’s DSM (DSM III), was at one time involved in a dispute with the psychoanalysts when he wanted to eliminate the term “neurosis” from DSM III. Neurosis is a broad umbrella term used to describe many forms of psychiatric distress, and this includes states of anxiety, obsessions, phobia and hysteria.
Neurosis is an inseparable element from Freudian psychoanalysis and is believed to arise from the unconscious internal conflict. The term was frequently used in DSM I and II. However, as far as Spitzer was concerned, it didn’t help matters, given his anti-Freudian tendencies which resulted in much resentment. He ran the risk of scuttling the entire DSM project without support of the psychoanalysts. After instruction by the APA to include the psychoanalysts in deliberation over the manual, both sides eventually reached a compromise. The term neurosis was to be retained, albeit in discreet parentheses for three or four key categories.
Besides the psychoanalysis drama, the homosexuality issue provided another hot spot of controversy. A psychiatrist and gay rights activist, Ronald Bayer, in his 1981 book entitled Homosexuality and American Psychiatry: The Politics of Diagnosis elucidated the protest by gay rights activists against APA which took place in the 1970s when the organisation held its conference in San Francisco. The activists disrupted the conference, interrupting speakers and ridiculed psychiatrists who viewed homosexuality as a mental disorder. Homosexuality was listed as a sexual deviation disorder in DSM II. Spitzer eventually brokered a compromise that resulted in the removal of homosexuality from the DSM.
The removal of homosexuality from the DSM naturally prompted protests over the political nature of the removal, rather than one based on scientific evidence. However, given the highly charged emotional undertones of the issue, it is easy to miss the woods for the trees. The larger picture being referred to is the evolution of psychiatry as a scientific discipline. Alix Spiegel’s article entitled “The Dictionary of Disorder” published in the Annals of Medicine section of New Yorker gave an elaborate account of the development of scientific foundation of the psychiatry discipline.
Spiegel described the field of psychiatry as a young discipline in crisis during the 1960s. Against this backdrop, it must be noted that DSM II (where homosexuality was included as a disorder) was published in 1968. The problem with psychiatry was that it suffered from what is known from the scientific perspective as the lack of reliability. Psychiatrists could not agree on which patient was sick and what was ailing them. A patient who was diagnosed with one disorder by one psychiatrist could be diagnosed as suffering from another disorder by another psychiatrist. This prompted criticisms over inability of the discipline to produce a constant, replicable result.
Studies have also proven the lack of diagnostic agreement among psychiatrists when presented with the same patient, and given the same information about the latter. Psychologist Philip Ash tested three psychiatrists with the same patient and three were given the same information, but they only reached the same diagnostic conclusion twenty percent of the time. A 1962 paper by Aaron T. Beck, the founder of Cognitive Behavioural Therapy founded the same trend on the lack of diagnostic agreement. Beck’s study found rates of agreement at thirty-two and forty-two percent, which are not encouraging numbers since nature of diagnosis determines the basis of treatment and patient management.
It comes across as disconcerting with a member of Spitzer’s DSM III task force team, Theodore Millon, admitting that the science has not been done as far as the discipline is concerned, and that “there was very little systematic research, and much of the research that existed was really a hodgepodge—scattered, inconsistent, and ambiguous. I think the majority of us recognized that the amount of good, solid science upon which we were making our decisions was pretty modest.” As a result, psychiatry as a discipline came under attack and earned the label of “pseudo-science”.
Thus, for those who are questioning the scientific basis of excluding homosexuality from the DSM, such a question is moot, and not a relevant one. This is because we have to presuppose that homosexuality is scientifically proven as a mental disorder which on that basis justifies its inclusion into the DSM, and a scientific basis is required to exclude it from the DSM. However, as it is, the scientific foundation of psychiatry during its early days concurrent with the production of early editions of DSM is anything but sound. Even at the stage of DSM III (homosexuality is removed at the seventh printing of DSM II) production, it has been pointed out by a task force member that the scientific foundation and research within the discipline is not sound. Thus, the implication is that homosexuality is included in the DSM not under scientifically rigorous conditions.
Arguing that there is no scientific basis in removing homosexuality from the DSM is analogous to the following situation – adherents to the flat Earth theory pushing for the inclusion of the physical law that our Earth is flat into an ultimate canon of Physics; the law was included into the canon without much scientific basis. One day, a group of anti- flat Earth theorists came along and protested and the law was removed from the canon out of political purposes seemingly, and the flat Earth theorists accused the removal of being done without any scientific basis. The inclusion was not scientific, or rigorously scientific to begin with. So, what is the accusation really about?
The debate over whether or not homosexuality is a mental disorder raises the issue about what we as individuals and the medical profession rationalise as a mental disorder or what is pathological (something gone wrong in layman terms). A glance through the most recent text revision version of DSM IV (DSM IV- TR) yields a common recurrent theme in the diagnoses of most mental disorders, ranging from mood and personality to even sexual disorders – the (in)ability of the sufferer to function in social situations, within his occupation or/and his (in)ability to maintain interpersonal relations. This general theme of diagnosis recapitulates the view of one of the attributes that constitutes a normal individual – the ability to maintain relations, interact with others or function as a member of the society in one’s daily life. This function is also captured in health-related quality of life (HRQOL) measures that patients may be evaluated for in clinics through filling in a questionnaire, one example of such is the WHOQOL-BREF, a World Health Organisation project that was developed collaboratively in a number of medical centres worldwide. Thus, it can be said that one of the determining factors of quality of life is the ability to form meaningful relationships or friendships and interact with other members of the society.
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