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The Great "Crazy" Coverup: Harm Results from Rewriting the History of DSM

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Another example of deceitfulness was that the IV Task Force announced that Self-defeating Personality Disorder would not go in their edition because the science did not warrant its inclusion (Caplan, 1995). Years later, a colleague doing research in the DSM archives came across an internal memo from an executive of an APA district branch revealing that the decision had been political. [11]

Kirk et al. (2013) correctly report that in work on 5, to avoid conflicts of interest, all Task Force members had to disclose financial ties to Pharma, and that no such disclosure was required for previous editions. But that does not mean there were no such conflicts in previous editions or that the disclosures required for 5 were effective. I have some direct experience with this for 5. Asked to write a magazine article about what was in store for PMDD in the fifth edition (Caplan, 2008), I emailed Dr. Jan Fawcett, head of the Mood Disorders Work Group, saying I was a psychologist writing a magazine article about PMDD. In our phone interview, he mentioned the much-publicized announcement that anyone on a DSM-5 committee would be required to divest themselves of drug company money. But he spontaneously revealed that that divestment was only required during their service on the committee, and they could even receive up to $10,000 a year from Pharma even during those years. He disclosed other worrying information as well. I turned in my article, and a magazine staffer called to say that in her factchecking conversation with Fawcett , he claimed that I had failed to disclose to him that I was writing an article for a magazine, and he had thought he had been having a casual talk with a colleague. I promptly resent him my first email message.

Frankly unethical is that, despite attacking others for lack of transparency, Frances takes it upon himself to decide which truths to conceal from the public, allegedly for their own good, because Frances and his colleagues know best: "sometimes we need a noble lie" (Greenberg, 2013, 156). He told Greenberg that he did not want to reveal all of the "Wizard of Oz stuff" (156), a striking statement, given that in 1991 I referred to him as the DSM Wizard because of the history of deception (Caplan, 1991).

The most notorious example revealing blatant falsehood related to the DSM is Greenberg's publication of Frances's statement that psychiatric diagnosis "is bullshit" (2013, 278), [12] which starkly conflicted with his multitude of assertions that his work on diagnosis had been scientific. Frances to Greenberg's revelation responded by accusing Greenberg of being "Paula Caplan in drag" (278), and my amusement on learning of that preceded the realization that he was equating Greenberg with me as tellers of the truth about him.

 

   The Bereavement Hoax

According to the Centers for Disease Control, nearly 2 1/2 million Americans died during the most recent year for which statistics are available. Using a conservative estimate that four people are seriously affected by each death, at least 10 million Americans are bereaved each year. Add the figures for the dozens of countries where the DSM is sold, and it is not surprising that the proposal to call bereavement a mental illness provoked perhaps the greatest outcry [13] of any DSM-5 proposal. Frances (2010) warned that once the new edition appeared, the bereaved would be called disordered, saying with ingenious wording that the "bereavement exclusion" would be "eliminated" from the new manual, as though the bereaved had been safe from being psychiatrically labeled during the reign since 1994 of DSM-IV.  This elicited the fury of many bereaved people, including some from the website of parental grief expert Joanne Cacciatore ( http://missfoundation.org/ ). It is important that Frances's implicit message was that in DSM-IV, therapists were instructed not to diagnose grief as mental illness. 

I.F. Stone would have done what apparently no journalist, academic, therapist, or bereaved person did: He would have checked the verity of Frances's claim about IV, and he would have found this: Anyone reading the entire listing for Major Depressive Episode (MDE) -- and almost no one ever does -- must plow through four pages of dense text to find even the first time that bereavement is mentioned. It begins with the statement that MDE should not be diagnosed if someone has been bereaved within the past two months. That is alarming, because bereavement does not end or, often, even diminish much after sixty days, nor should we expect it to. But it gets worse: T he statement about the two-month leeway does not end the sentence; it is followed by a comma and the following words: " unless they are associated with marked functional impairment or include morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation " (p.352 of DSM-IV-TR, italics added ). Note especially the word "or" throughout the foregoing. One need meet only a single criterion in that list to qualify for MDE even as soon as the first day of bereavement. Who in their right mind would call that a bereavement exclusion? Furthermore, in the MDE listing in IV the differential diagnosis section includes no mention at all of bereavement and certainly no bereavement exclusion.  

As Horwitz and Wakefield wrote in their book, The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder, "a strange case of two "wrongs' seemingly making a "right': The DSM provides flawed criteria that do not adequately distinguish disorder from nondisorder; the clinician, who cannot be faulted for applying officially sanctioned DSM criteria [my italics], knowingly or unknowingly misclassifies some normal individuals as disordered" (Horwitz & Wakefield, 2007, p. 214). [14] I disagree that the clinician cannot be faulted for the reason they state, because every clinician should be required not to accept uncritically whatever a lobby group produces. It would surely be unacceptable for an oncologist, for instance, to diagnose someone with "Cancer Q," an allegedly newly discovered cancer announced by a lobby group or drug company, unless that oncologist has read and thought critically about the research put forward to support the claim that a new cancer -- and/or treatment for it -- has been discovered.

Some of Cacciatore's followers told me, and I have heard from individuals beginning in 1994, that DSM-IV had indeed over the decades been used to classify bereavement immediately as mental disorder (MDE). Probably everyone reading this knows someone whose normal grief was diagnosed as MDE and who was likely medicated as a result. Lacasse and Cacciatore (2013) documented the psychiatric drugging of bereaved parents during the time of DSM-IV, even on the first day of their child's death, clear sign of the longstanding medicalizing of grief.

Here's another fact: The DSM-5 allows a bereaved person two weeks before they qualify for MDE, an appallingly brief time but two weeks longer than DSM-IV allowed. The new version is also better (everything is relative), because to qualify for MDE if you are bereaved, you have to have at least five of the symptoms they list rather than just the one required in IV. Best of all, of course, would be to stop calling bereavement a mental illness.

I told BBC radio producer Gemma Newby about the Bereavement Hoax about DSM-IV, citing page numbers and all, shortly before the DSM-5 appeared. However, when her segment aired -- and it remained on the BBC website only a few days afterward [15] -- it was based on the false notion that there had been a bereavement exclusion in IV, and it valorized Frances for warning of the allegedly far worse listing to come. As Davies (2013) and others note, Lancet and the New England Journal of Medicine published railleries against what they called elimination of the bereavement (so much for factchecking by editors of respected medical journals), and the false claim that DSM-IV's MDE listing had a bereavement exclusion is perpetuated in recent books about psychiatric diagnosis whose authors otherwise include a great deal of excellent material   (Davies, 2013; Greenberg, 2013; Kirk et al., 2013).

Similar misrepresentations of other labels from IV were rampant, but space limitations necessitate limiting the discussion here to this one.

Use of Language to Rewrite History 

As I learned when assessing media reports of DSM-IV debates (Caplan, 1995), and as noted above, journalistic as well as professional and academic writers use linguistic signposts to validate or disparage the credibility of their sources. For example, critics of diagnosis may be branded as "anti-psychiatry" (Frances, 2013, 243; Greenberg, 2013,278 [16] ), just as critics of government policy may be called "anti-American." By this means, responsible and legitimate questioners of diagnostic validity are cast as opponents of the entire project of psychiatry and its practitioners, hence cranks or reactionaries unworthy of attention.

"Anti-psychiatry," like "anti-American," treats every particularized criticism as a universal condemnation in order to discredit the critic. The label falsely suggests that raising legitimate questions is equivalent to delegitimizing the work of all psychiatrists. Furthermore, this characterization signals that the debate is only about psychiatry, when in fact the diagnosis of mental disorders governs the daily work of psychologists, social workers, counselors, marriage and family therapists, and even some clergy. The term portrays advocates and critics as primarily opposed to some people rather than concerned about helping those who have been or will be harmed. Public attention is thereby diverted from the vast and real harms done by diagnostic labeling within these non-psychiatric professions as well as health insurance and government services (Medicare, Medicaid, the armed forces, and the VA cover mental health care only for those having official DSM diagnoses).

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Paula J. Caplan, Ph.D., is an advocate, activist, clinical and research psychologist, and awardwinning nonfiction author and playwright. She is Associate at the DuBois Institute, Harvard University, and a past Fellow in the Harvard Kennedy (more...)
 

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