By Eric Vandenbroeck and
co-workers
The
secrets behind the making of the Diagnostic and Statistical Manual of
Mental Disorders(DSM)Part Three
Manufacturing
Depression: The Secret History of a Modern Disease and contributor to The New Yorker, Mother
Jones, The New York Times, and other publications, Greenberg is a
practicing psychotherapist. The Book of
Woe: The Making of the DSM-5 and the Unmaking of Psychiatry is his exposé of the business behind creating the new
manual.
But there is more than that:
This while in Part One
of our overview we focused among others on its
protagonist Robert L. Spitzer and the construction of DSM-III.
In Part Two we focused on among others bot the
intra-professional external forces involved with DSM-IV
and DSM-5 revision attempts. Yet observable symptoms persist in
defining the DSM diagnoses, a situation that general medicine surmounted more
than a century ago. The chemical and physical operations of the brain have yet
to provide clues that may unravel the mysteries of human consciousness and its
distortions. Mental disorders could require understandings that cannot be
completely removed from personal life experiences. The future of the DSM is
clearly at a crossroads, but the path it should take has no roadmap.
Expanding Pathology?
Each DSM has grappled
with how broad a range of pathology the manual should encompass. The DSM’s
history is marked by its increasing medicalization of emotions and behaviors in
one narrative. This accounts for the growth of DSM diagnoses from 106 entities
in the DSM-I to 182 in the DSM-II, 265 in the DSM-III, and 292 in the DSM-IV 5.
Much of this expansion involves medicalizing phenomena that had been seen as
normal or immoral.
37Much of this
expansion involves medicalizing phenomena that had been seen as normal or
immoral.
For some,
“medicalization” is a descriptive, not evaluative, term that does not judge
whether the trend is desirable or undesirable. This group notes how diagnoses
of mental disorders have expanded horizontally to encompass new forms of
pathology and vertically to capture milder forms of conditions that previously
required greater severity.28 Many critics, however, see growing medicalization
as pernicious and strive to “protect normality from medicalization and
psychiatry from overexpansion.”29 A third view, illustrated by anthropologist
Roy Grinker’s assessment of the growth of autism diagnoses, celebrates the
benefits such as better access to treatment and services, lower levels of
stigma, and improved research that this trend has brought about: “The prevalence
of autism today is a virtue, maybe even a prize.”30
The range of behavior
that falls under the legitimate authority of psychiatry has increased, as
Spitzer observed. The larger diagnostic categories in the DSM-III than DSM-II
reflect the clinical and research need for greater specificity in describing
behavioral syndromes.31 It is less clear, however, that the mental disorder
itself has grown over the past 20 years.32 The DSM-I and II already encompassed
much of the more detailed criteria sets that arose in 1980.33 There is marked
variation in the degree of newly medicalized conditions across the major
classes of mental disorders.
Disorders among
children and adolescents provide the clearest examples of how the DSM has
increasingly medicalized previously nonmedical conditions. The initial DSM paid
almost no attention to mental disorders among young people. It mentioned autism
as a symptom of childhood schizophrenia and briefly described three categories
of adjustment reactions in infancy, childhood, and adolescence. The DSM-II
expanded this class, adding seven diagnoses to the original DSM-I conditions.
Its category of behavior disorders of childhood and adolescence was 1 of just
11 major classes.34
The DSM-III greatly
accelerated the enlargement of diagnoses among youth with a class renamed
“disorders usually first evident in infancy, childhood, or adolescence.” The
manual placed this category first among its 15 general diagnostic classes. In
contrast to the 3 pages the DSM-II devoted to this group, the DSM-III took 65
pages to describe 46 different criteria sets.35 The following two revisions
continued to broaden this class, especially for attention-deficit /
hyperactivity disorder, autism, and Asperger's, a condition that first appeared
in the DSM-IV. One result was that diagnoses of ADHD surged from less than 1
percent in 1980 to over 10 percent of children in 2011.35 Another was that
rates of all forms of autism expanded from just 1 in 2,000 children in the
1970s and 1980s to 1 in 68 when the DSM-5 was published in 2013.36 The DSM-5
did not continue the growing medicalization of mental disorders among youth but
moved many of the former age-defined diagnoses to their substantive homes
(e.g., separation anxiety went to the anxiety disorders section; conduct
disorder to disruptive, impulse, and conduct disorders). Its new class of
neurodevelopmental disorders had significantly fewer categories than the child
and adolescent class it replaced.
The bipolar II
diagnosis that entered the DSM in 1994 provides another example of expanding
pathology. This condition combined the easy-to-meet MDD criteria with a single
hypomanic episode of at least four days’ duration. A disorder that historically
affected about 1 percent of the population came to encompass about five times
that number.37 It became the first DSM diagnosis to create a mass market for
antipsychotic drugs.
The DSM-5’s expansion
of the class of substance use disorder to encompass substance-related and
addictive disorders provides a third instance of the extension of mental
disorder into a new realm. The addition of an addictive category that is not
substance-related has huge potential consequences. While the DSM-5 text
incorporates only gambling disorders in the new category, the manual includes
internet gaming disorder among its conditions for further study. Virtually all
(90 percent) Americans are now online, spending an average of between 18 and 24
hours a week on the internet.38
This figure increases
to about nine hours a day among teenagers.39 This change potentially extends
the notion of “addiction” from its traditional application to substances that
induce compulsive consumption to virtually any activity that people frequently
engage in, such as sex, shopping, eating, and exercising.40 The DSM’s possible
colonization of this huge new realm might realize Karl Menninger’s belief that
“most people have some degree of mental illness at some time, and many of them
have a degree of mental illness most of the time.”41
Medicalization
displays a less straightforward trajectory for other major DSM classes. The
DSM-I is called psychoneurotic disorders, and the DSM-II neuroses had few
specific categories but extensive reach. Outpatient psychiatrists and
physicians could apply its vague formulations to the psychic consequences of
poor marriages, economic worries, failed ambitions, and general nervousness.
While the DSM-III and the manuals that followed it contained a far greater
number of specific diagnoses, they did not expand
the amount of pathology that the broad neurotic categories of the initial DSMs
already captured.
The class of anxiety disorders
also shows how more diagnoses need not indicate a growing medicalization of
previously normal emotions. Although the DSM-I and II had fewer specific
anxiety diagnoses than the manuals that followed, they provided a more
expansive conception of this condition. The DSM-II conception was exceedingly
broad: “Anxiety is the chief characteristic of the neuroses. It may be felt and
expressed directly or controlled unconsciously and automatically by conversion,
displacement, and various other psychological mechanisms. Generally, these
mechanisms produce symptoms experienced as subjective distress from which the
patient desires relief.”42 The greater number of anxiety diagnoses in
subsequent manuals did not expand pathology but more precisely defined conditions
that earlier manuals had incorporated into their broad categories.43
The personality
disorders are another case where recent DSMs are not more medicalized than were
their predecessors. Although this class's particular types of conditions
changed considerably over the DSM era, neither their number nor their range
increased. The first two DSMs presented capacious portrayals of 12 personality
disorders that spanned from the most introverted to the most antagonistic and
many character types in between.44
Subsequent manuals
added some conditions, abolished others, and changed the criteria for still
others, but the DSM-5 maintains diagnoses for 12 personality disorders.45
PTSD illustrates a third
type of diagnostic trajectory that fluctuates in scope over the DSM period.
Although the cultural presence of trauma-related diagnoses has expanded
tremendously since 1980, gross stress reaction, growing out of the professional
experiences of military psychiatrists in World War II, was a central diagnosis
in the first DSM. Trauma-related diagnoses contracted in the DSM-II only to be
resurrected in the DSM-III’s PTSD diagnosis. The broadening definitions of
“trauma” in the PTSD criteria of the DSM-III-R and DSM-IV helped bring about an
explosion of traumatic diagnoses.46 The DSM-5 changes to the PTSD diagnosis,
however, constituted a rare example of an attempt to reduce the number of
diagnoses through narrowing the scope of relevant traumas and limiting
traumatic exposure to actual events.47 The revised criteria set reversed the
consistently growing expansion of PTSD from the DSM-III to the DSM-III-R and
the DSM-IV.
The development of
the disruptive mood dysregulation disorder (DMDD) in the DSM-5 is another
unusual case of an attempt to reign in diagnostic expansion. The spectacular
growth of pediatric bipolar disorders and resulting prescriptions for
antipsychotic drugs was a huge embarrassment to the psychiatric profession in
the early 2000s. The major proponents of PBD, Harvard psychiatrist Joseph
Biederman and his associates, had received more than $4 million from
Johnson & Johnson, the maker of the antipsychotic drug Risperdal. The
resulting scandal generated widespread negative publicity, including front-page
stories in the New York Times and a widely viewed segment on 60 Minutes about a
four-year-old who died from an overdose of drugs prescribed for her “bipolar
disorder.”48 At the same time, the disruptive, oppositional, and irritable
children diagnosed with PBD posed major behavior problems for their parents and
others. The DSM-5 workgroups on childhood and adolescent disorders developed an
ingenious solution to the combination of the public repudiation of PBD and
parental demands for some treatment. After some missteps, they created a DMDD
diagnosis that combined symptoms of irritable mood and aggressive behavior.49
They placed it within the depressive disorders, not the bipolar and related
disorders class, which severed its connection with the cycling of bipolar
conditions that required powerful drugs. This placement signaled a departure
from PBD and its attendant need for antipsychotic medication, yet preserved a
diagnosis that would help parents deal with their troublesome children.50
A final category
encompasses unsuccessful attempts to medicalize behaviors. The failed proposal
for a psychosis risk syndrome in the DSM-5 provides perhaps the most prominent
example. As the previous chapter discussed, the PRS diagnosis strove to identify
persons who did not meet the criteria for psychosis but were thought to be at
risk of developing one in the future. This attempt to greatly expand the realm
of pathology met intense opposition, and the DSM-5, like its predecessors,
lacks any diagnosis related to the risk of becoming mentally ill.
The depiction of an
ever-growing realm of mental disorder that encompasses new forms of pathology
and milder forms of previously recognized illnesses is, therefore, an
overgeneralization. Childhood and adolescent disorders, the new class of
addictive behaviors, and bipolar II illustrate a growing array of pathology to
incorporate phenomena previously viewed as mental disorders. Yet, despite
alterations in many of their particular criteria sets, the range of other
diagnoses, such as anxiety and personality disorders, has not incorporated
non-pathological conditions previously. Some conditions, like PTSD, have both
expanded and contracted over time. Finally, as PRS shows, some attempts at
medicalization have failed. Almost no categories, however, have completely
disappeared from the DSM, homosexuality being the rare exception.
Critics who object to
the growing medicalization of previously nonmedical conditions argue that the
expansion of mental disorder pathologizes normal experiences, stigmatizes the
recipients of diagnoses, and generates unnecessary and often harmful treatments
for people who don’t need them. In addition, they note how treating
non-disordered conditions takes resources away from those who genuinely could
benefit from therapies.56 These critics are unlikely to succeed. Regardless of
their validity, these arguments are likely to hold little weight in the face of
the substantial benefits that DSM diagnoses reap for many groups. Interests that support their maintenance or expansion include:
The professional,
industry and lay interests in preserving or increasing the number of diagnoses
will likely continue to enfeeble objections to growing amounts of
pathology.
On the Threshold?
Gerald Grob’s
synopsis captures the history of psychiatry: Every generation since the
nineteenth century, the specialty has stood on the threshold of fundamental
breakthroughs that would revolutionize how mental disorders were understood and
treated. In the mid-twentieth century, psychodynamic and psychoanalytic
psychiatry became the vehicle by which the mysteries of normal and abnormal
behavior would be revealed. At present, the road to salvation is presumably
through biological psychiatry, neuroscience, and genetics.57
As it enters the
third decade of the twenty-first century, is psychiatry closer to revealing the
mysteries of mental disorder than it was when the first DSM appeared? In one
prominent telling, the DSM’s evolution represents a tale of steady, if uneven,
progress. The accumulation of new findings has led the manual to ever-better
approximations of the reality of mental disorders. Prominent psychiatrists
speak of how “scientific evidence” has replaced the charismatic authority of
“great professors” in the evolution of the DSM.58 The APA website lauds the
DSM-5 Task Force: “Their dedication and hard work have yielded an authoritative
volume that defines and classifies mental disorders to improve diagnoses,
treatment, and research.”55 Indeed, some developments, the replacement of
analytic assumptions with theory neutrality, the recognition that intense
social stressors can produce lasting mental disorders, the removal of
homosexuality, the acknowledgment of autistic disorders, seem to improve the
manual. Few psychiatrists would prefer the always-perfunctory and sometimes
analytically infused definitions that prevailed before the DSM-III to the
current DSM-5 diagnoses.
Others paint a more
skeptical picture of the history of the DSM. In their portrayals, the
medical-like diagnoses that arose in the DSM-III are artifices that disguise
psychiatry’s continuing lack of progress in understanding the causes,
prognoses, or optimal treatments for any of its major conditions. For example,
sociologist Owen Whooley observes how every edition of the manual continues to
camouflage psychiatry’s fundamental ignorance about the basic nature of the
mental illness.56 Historian Edward Shorter goes further, contending that the
current classification is inferior to that of the original DSMs: “The diagnoses
that flourished in the middle third of the twentieth century did a better job
of cutting Nature at the joints than many of the diagnoses we have today, which
are artifacts born of political compromises and sustained by pharmaceutical
promotion rather than scientifically accurate descriptions of what is actually
wrong with someone.”59 For such critics, the major issues the DSM has had to confront
over the past 70 years are no closer to resolution now than when the manual
first arose.
Despite advances in
brain-imaging technologies, psychiatry remains as reliant on observable
symptoms as it was in the eighteenth century when Thomas Arnold wrote, “When
the science of causes shall be complete, we may then make them the basis of our
classification, but till then we ought to content ourselves with an arrangement
according to symptoms.”60 Like all psychiatric classifications that preceded
it, the DSM system must still use reported symptoms as the raw material for
constructing its diagnoses. No attempt to develop etiologically informed
diagnoses has yet to succeed.
The reliance on
external symptoms especially hampers the construction of adequate definitions
of the nature of the mental disorder itself. One central, perhaps the central,
issue regarding the DSM is what makes any of its diagnoses mental disorders.
The DSM-I and II did not try to answer this question. Psychiatry was so well
respected in the postwar period that no one questioned the field’s authority to
define its subject matter. This situation radically changed in the late 1960s
and early 1970s when anti-psychiatry, gay, and feminist activists challenged
the field’s authority over what the term “mental disorder” should encompass. At
the same time, strong cultural, political, and economic forces pushed
psychiatry to conceive of its subject manner as disease entities comparable to
those in the rest of medicine. Beginning with the DSM-III and persisting
through the present, diagnoses reflect the idea that mental disorders, no less
than physical diseases, have their own reality independent of particular life
experiences. However, extracting symptoms of mental disorder from the contexts
in which they arise is considerably more complicated than isolating symptoms is
in the rest of medicine.
A major
obstacle Robert Spitzer faced was that a core principle of the
DSM-III revolution was to use observable symptoms without regard to their
underlying causal mechanisms to define each diagnosis. The turn to classifying
mental disorders by their outward appearances hindered the ability to separate
mental disorders from symptomatically similar but contextually explicable
responses and disliked and devalued but not disordered responses.
Many psychiatrists
did not bother with the absence of a definition of “mental disorder.” Why
should psychiatry be different from other branches of medicine? This objection
persists. For example, when a person has a myocardial infarction (MI),
physicians regard it as an instantiation of cardiac disease, regardless of its
context.61 For Pies and others, just as a heart attack is a heart attack, a
mental illness is a mental illness. Therefore, like the rest of medicine,
context is irrelevant to separating psychiatrically disordered symptoms from
situationally apt or culturally appropriate expressions.
Yet Spitzer realized
that defining “disorder” is fundamentally different, and far more challenging,
in psychiatry than physical medicine. Separating organic symptoms from the
settings was a hallmark of diagnostic progress in other medical specialties.62 In
psychiatry, divorcing symptoms from context has the opposite impact of
hopelessly blurring situationally appropriate psychological phenomena from
mental disorders. This is because all mental functions are susceptible to
environmental circumstances. Virtually every symptom of various mental
disorders can sometimes be biologically and psychologically suitable
adaptations to given contexts, culturally explicable expressions, or both. For
example, symptoms resembling depression that arise after the death of a loved
one indicate that grief mechanisms are working appropriately, not
inappropriately. Likewise, a panic attack is an understandable response when
facing an impending fall off a cliff but a sign of disorder in the absence of
danger.63 Or hearing voices, which can be a hallmark of schizophrenia, is
sometimes explicable in particular cultural and religious settings.64 In
contrast, a heart attack always signals a failure of natural functioning
regardless of the context or culture in which it emerges. Unlike other medical
specialties, context is an intrinsic aspect of deciding what a mental disorder
is or is not.65
Spitzer understood
the difficulties of developing a general definition of “mental disorder”
entailed but realized such a statement was necessary to establish the field’s
credibility and protect it from anti-psychiatry attacks. His original
formulation has mostly endured through the present DSM-5 version:
A mental disorder is
a syndrome characterized by clinically significant disturbance in an
individual’s cognition, emotion regulation, or behavior that reflects a
dysfunction in the psychological, biological, or developmental processes
underlying mental functioning. Mental disorders are usually associated with
significant distress or disability in social, occupational, or other important
activities. An expectable or culturally approved response to a common stressor
or loss, such as the death of a loved one, is not a mental disorder. Socially
deviant behavior (e.g., political, religious, or sexual) and conflicts that are
primarily between the individual and society are not mental disorders unless
the deviance or conflict results from a dysfunction in the individual, as
described above.66
This characterization
both expresses what mental disorders are, dysfunctions of some mental processes
that are not working as they should and that lead to distress or disability,
and what they are not, culturally defined deviant behaviors or conflicts between
individuals and society. The DSM’s succinct definition identifies both
essential aspects of mental disorders and separates them from states that are
often mislabeled as psychiatric problems.66
Spitzer knew the
definition couldn’t set an exact boundary between dysfunctions and normal-range
behaviors because no sharp division exists in nature. The borders between
mental disorders and non-disordered states of distress or social deviance are
often fuzzy, vague, and ambiguous. Despite this caveat, the statement
serviceably separates distressing states from those of mental disorders. When
the DSM diagnosis takes this general definition into account, they should
strike the best balance between recognizing true disorder cases and weeding out
contextually appropriate or socially devalued behaviors.67
The central problem
has been that, in practice, many of the particular DSM criteria sets don’t
follow the definition.68 Worse, criteria for what makes some core diagnoses
mental disorders have deteriorated, rather than progressed, over time.
Depression provides probably the most egregious example; succeeding DSMs have
increasingly relied on external symptoms without regard to the context in which
they arise. The first DSM directed clinicians to consider “the realistic
circumstances of the loss,” The DSM-II treated only “excessive” symptoms as
signs of a disorder.69 The three DSMs that followed provided far more
symptom-based criteria sets for MDD but excluded uncomplicated symptoms that
arose from bereavement from diagnosis. The DSM-5 criteria set eliminated even
this exception.70
Because depressive
symptoms need to last just two weeks, they can easily be short-lived responses
to events rather than true disorders. Far from being “on the threshold” of
growing understandings, the context-free DSM-5 MDD diagnosis shows even greater
heterogeneity and indistinct boundaries with normal sadness than its
predecessors.
In other cases, DSM
criteria do not separate mental disorders from social deviance. The history of
substance use disorder (SUD) diagnoses recounted in the previous chapter
provides the primary example of this type of growing conflation. The first two
DSMs placed most SUD diagnoses among conditions that involved brain damage. The
DSM-III greatly broadened this category by adding to addictive behaviors a new
abuse diagnosis that referred to the problematic social consequences of
substance use. Abuse and addiction remained separate diagnoses in subsequent
revisions until the DSM-5 combined them into a single category, in defiance of
the admonition in the manual’s definition of mental disorder to avoid
mislabeling social deviance as dysfunction. Instead, the new criteria for SUD
blur dysfunctions that stem from addictions with rule violations and social
impairments.
In other cases, diagnoses
do not distinguish dysfunctions from conflicts between individuals and society.
The new diagnosis of hoarding disorder in the DSM-5 illustrates this situation.
Its essence is “persistent difficulties discarding or parting with possessions
regardless of their actual value.”7051 Hoarders typically accumulate so many
items that they or others have difficulty navigating their living spaces. This
telegenic situation has become the object of a popular television series,
Hoarders. Yet, the new diagnosis potentially involves many false-positive
problems: hoarders themselves are typically not troubled by their condition
unless someone tries to stop their stockpiling. Interventions typically arise
after family members, neighbors, or public health departments complain. The
justification for calling hoarding behaviors “dysfunctions” or “mental
disorders” as opposed to “conflicts between individuals and society” is
unclear.71
Although the overall
narrative of growing diagnostic progress over the DSM era is, at best,
questionable, the DSM-5 did take some steps to distinguish mental disorders
from other conditions better. One was replacing the former little-used Axis IV,
psychosocial and environmental problems, with a new chapter on other conditions
that may focus on clinical attention. The DSM-5 forthrightly states, “The
conditions and problems listed in this chapter are not mental disorders.”72
They encompass relational difficulties; abuse and neglect; and educational,
occupational, housing, legal, and economic problems. Including a wide range of
psychosocial, personal, and environmental difficulties that are explicitly not
mental disorders could help clarify the hazy boundaries between mental
disorders and contextually appropriate distress that characterized previous
manuals.
The DSM-5 also took
steps to incorporate cultural differences in symptomatic expressions into
account. It includes a whole chapter on cultural formulation based on the idea
that “understanding the cultural context of the illness experience is essential
for effective diagnostic assessment and clinical management.” Many of its
particular criteria sets note these differences. For example, GAD symptoms can
present somatically in some cultures and cognitively in others. In
schizophrenia, “ideas that appear to be delusional in one culture (e.g.,
witchcraft) may be commonly held in another. In some cultures, visual or
auditory hallucinations with religious content (e.g., hearing God’s voice) are
a normal part of religious experience.”73 Overall, the latest manual is more
attentive to errors resulting from mistaking cultural differences with mental
disorders. Still, future DSMs will continue to face challenges in
distinguishing psychiatric dysfunctions from contextually and culturally
explicable responses and social deviance.
Future DSMs
The DSM’s evolution
reveals the huge and possibly unresolvable difficulties in defining mental
disorders. At first, the manual’s developers bet that combining organic
conditions found in asylums with a psychodynamic model that captured the
problems of outpatients was sufficient to meet psychiatry’s diagnostic needs.
Next, they embraced a medical model that assumed a basic resemblance between
mental and physical disorders but refrained from theoretical speculations about
their causes. The DSM-5 unsuccessfully tried to adopt the statistical
techniques and dimensional measurements of psychological research to define its
conditions. The latest, as yet totally unrealized, efforts assume that
neuroscientific research will point the manual in a more brain-based direction.
Whether the research domain criteria, the NIMH’s ambitious new diagnostic
system grounded in neural circuitry, will succeed is far from assured at
present.
The current DSM
contains 22 general classes and nearly 300 specific diagnoses. Yet perhaps the
most striking finding from neuroscientific research is that the hundreds of DSM
diagnoses reflect variations on a small number of general processes that are loosely
related to internalized, externalized, and psychotic disorders.74
However, a DSM
organized around just three classes would be professionally unthinkable: such a
system would have no medical authority. The lack of alternatives to using
external symptoms as the basis for diagnosis ensures that future DSMs are
unlikely to result in fundamental breakthroughs in understanding and treating
mental disorders.
The DSM-5 process
sunk the credibility of the manual to levels not seen since the 1970s. Critics
were not the vociferous anti-psychiatrists who objected to earlier versions but
eminent figures within the profession, including Spitzer and Frances, the chairs
of earlier DSM revisions, and former NIMH directors Steven Hyman and Thomas
Insel. The leaders of the DSM-5 Task Force themselves vigorously critiqued the
manual. Only after their efforts at paradigm change failed did they revert to
defending the extant diagnostic system. The major guardians of the
classification were clinicians who were skeptical about the DSM’s validity but
required its diagnoses for practical purposes. Will it be possible to resurrect
the DSM enterprise?
The DSM-III era seems
to be over: researchers no longer respect the symptom-based DSM entities and
seek neuroscientific alternatives such as the RDoC.
On the opposite direction, calls arise to return to the era when psychiatry
focused on personal history and interpersonal connections. One group of British
psychiatrists calls for junking the DSM system because what they call “good
practice in psychiatry primarily involves engagement with the non-technical
dimensions of our work such as relationships, meanings, and values.”75
Despite continuing
frustrations over establishing a valid diagnostic classification, the DSM won’t
be replaced anytime soon. Patients require their diagnoses to obtain treatment,
and many other factors determine eligibility. The current DSM fulfills psychiatry’s
need for professional legitimacy; all medical specialties require specific
diagnoses. Despite these advantages, the DSM system will persist for years
because its diagnostic entities are closely intertwined with too many interests
to give up.
Observable symptoms
persist in defining the DSM diagnoses, a situation that general medicine
surmounted more than a century ago. The chemical and physical operations of the
brain have yet to provide clues that may unravel the mysteries of human
consciousness and its distortions. Mental disorders could require
understandings that cannot be completely removed from personal life
experiences. The future of the DSM is clearly at a crossroads, but the path it
should take has no roadmap.
Footnotes upon request by writing to
ericvandenbroeck1969@gmail.com
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