Monday, July 08, 2013


Mental Illness as Construct

"Here's the problem," Frances* said. "There is no definition of a mental disorder."

I mentioned that that hadn't stopped him from putting one into the DSM-IV, or the people who were then making the DSM-5 from fiddling with it.

"And it's bullshit," he said. "I mean you can't define it." [p. 23]

"the personality disorders are not at all clearly distinct from normal functioning or from each other," [p. 263; quoting Allen Frances; emphasis added]

What Insel heard "over and over again" on his tour [of "hospitals and universities around the country"] was that psychiatrists were tired of being trapped by the DSM. "we are so embedded in this structure," he told me. He and his colleagues had spent so much time diagnosing mental disorders that "we actually believe they are real. But there's no reality. These are just constructs. There's no reality to schizophrenia or depression." [p. 340]

"Whatever we've been doing for five decades," [Insel] told me, "it ain't working. And when I look at the numbers–the number of suicides, the number of disabilities, mortality data–it's abysmal, and it's not getting any better. All the ways in which we've approached these illnesses, and with a lot of people working very hard, the outcomes we've got to point to are pretty bleak–especially, he added, compared with the "extraordinary" progress in other fields, such as the 70 percent drop in mortality from cardiovascular disease since he went to medical school or the steep reductions in deaths from auto accidents and homicides. There are some people for whom some of what we do is enormously helpful," he said. But even so, "we don't know which treatments are working for which people." And this litany of failure, he said, "gets us back to your interest in nosology. Maybe we just need to rethink this whole approach." [pp. 351-352]

Source: Gary Greenberg. The Book of Woe: The DSM and the Unmaking of Psychiatry (Penguin, 2013).

    *Allen J. Frances, MD is the former head of the Duke University School of Medicine's psychiatry department and was once referred to by The New York Times as "perhaps the most powerful psychiatrist in America." Frances served on the American Psychiatric Association's (APA) personality disorders work group for the 1980 DSM-III. He was chair of the APA task force responsible for the 1994 DSM-IV.
     †DSM is an abbreviation for the APA's Diagnostic and Statistical Manual of Mental Disorders.
     ‡Thomas R. Insel, MD, is the Director of the National Institute of Mental Health.

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