A Concise History of the DSM

From a blog comment made by an anonymous commentator. (Note: NPD stands for Narcissistic Personality Disorder):


As a psychiatrist with personal experience with NPDs, I fully concur with Anna's views that this change in the DSM is essentially a non-event for all the reasons she enumerated. Perhaps some additional information about the DSM may be helpful in fully appreciating some of the reasons for its meretriciousness. (To save some of you from consulting a dictionary, "meretricious" is defined as apparently attractive but having in reality no value or integrity. I also use this word not unintentionally for its archaic meaning - of, relating to, or characteristic of a prostitute.)

Some of the individuals who first developed the DSM are well known among psychiatric circles to have severe NPD themselves. The interests of one DSM "innovator" in particular were in statistics and in ways to categorize knowledge generally. At the time in the 1960s, a dedicated system of classification of mental disorders was lacking. Previously these disorders were given codes in a manual called the International Classification of Diseases (ICD) along with all other medical disorders. Seeing an "opportunity," one DSM originator chose to go to medical school and specialize in psychiatry exclusively in order to have the credentials to create a classification system. Medicine and psychiatry were merely means to another end. The womb of the DSM resided in an obsessive individual who possessed a prominent dearth of humanity and who by the same token could have easily chosen to classify machine tools, toads or sea shells. In addition, for the initial DSM there was very little consensus. It is the product of just a few individuals. This was the inauspicious inception of the run-away train we now call the DSM.

Another critical point to remember is that the primary impetus for a classification of mental disorders was for research purposes - not for clinical utility. That is why it is a diagnostic and STATISTICAL manual. The use of medications in psychiatry began in earnest in the 1950s creating a need to do clinical trials. A system was needed to enable researchers to group individuals together diagnostically. One cannot for example do a trial of a drug for schizophrenia without defining the population for which the medication is purported to be effective. Thus the birth of the DSM and its subsequent revisions has been influenced in no small way by changes in the field of psychiatry and in pharmaceutical technology.

The pharmaceutical industry is not the only one that has influenced the evolution of the DSM. Since the 1980s, the health insurance industry has exerted an increasingly formidable influence on the way mental health disorders are viewed. Because it determines the reimbursement of treatment services, it creates demands on the field for the EXPLICIT purpose of decreasing expenditures. This industry has clearly had an impact on how individuals are diagnosed. In stage one, personality disorders were excluded from any reimbursement. The DSM then responded by creating all sorts of other reimbursable categories into which a psychiatrist could "fit" that patient. More recently the insurance companies for reimbursement considerations have created strata of severity of mental illnesses in which, for example, major depression, schizophrenia and full-blown bipolar disorder are reimbursed more fully than other less debilitating "disorders" such as adjustment disorders, anxiety disorders, etc.

Perhaps one day a historian will go back and rigorously track the developments in the DSM against the developments in the pharmaceutical and insurance industries. I am convinced that we will see clear concordance.

And as other industries as well as cultural views continue to pressure and influence how we view behavior, thought and "feelings," the DSM will follow in kind. One example is "Social Anxiety Disorder" as if there is one person who doesn't get anxious speaking in front of a group of people. The list of inane diagnostic classifications is endless.

In order to keep ahead of the game, the DSM revisionists employ two other strategies. The first has always been unspoken and is rarely contested: that all behavior, thought and "feeling" is under the purview of "mental health" and its soldiers, psychotherapists (psychiatrist, psychologists, etc.). Should tomorrow many people start snapping their fingers frequently, the DSMers would have a classification for that in the next revision. The underlying problem here is that there is no definition of "mental illness" or "mental disorder."

A fine example is just this topic: NPD. For years, I frequently have read laying down on my sofa and crossing my legs. Now I have a knee problem, one that the orthopedic surgeon can directly relate to my bad reading habits. With proper changes in behavior and stretching, the knee problem is much improved. So is the case with malignant narcissists. As this blog pointed out several times, "garbage in, garbage out." If one goes through life executing malice and then must distort the truth in order to not be caught, one's thinking will become disordered. That is NOT a mental disorder. It is the ramification of a habit over which one can exert control. The DSM makes no distinction between the ramifications of controllable and self-modifiable bad habits versus the ramifications of a process over which volitional control is impossible (e.g., schizophrenia).

The second DSM strategy is to create categorical buckets so over-inclusive that it is irrefutable. Hence nearly every "diagnosis" contains a "disclaimer" with language such as, "The present symptoms cannot be otherwise better accounted for by [another] diagnosis." Or, another sub-category is created to allow for any exception to the rule. This sub-category is termed "NOS" which stands for "Not Otherwise Specified." Thus if someone complains of depression of a type that does not fit exactly with the sub-types enumerated in the DSM, that depression is deemed, "Not otherwise specified."

Therefore the DSM "takes all comers." It is set up in a way that one cannot even attempt to challenge or refute it because it contains inherent escape clauses which are designed only to make it immune from any criticism. Thus it exists to perpetuate its own existence. It is a simulacrum; i.e., an image without the substance or qualities of the original. Simulacra may contain elements of truth (e.g., the DSM's description of schizophrenia), but due to the lack of definition, coherence, mission and integrity in its core being, its utility is best characterized by where my copy ended up.

One winter, I ran out of firewood...

One postscript. It may appear that the DSM committee is composed of "academics" and not clinicians. The distinction today is not very sharp as nearly all "academics" do clinical work. (I know not a few of them and can vouch for that statement). In my opinion, psychiatrists have thrown their hands up in trying to understand the "personality disordered" for which, not for nothing, they have little chance of obtaining research funding. And although they will never publicly admit it, they don't want to even see those "bad and difficult patients" anyway.