DSM: A History of Psychiatry's Bible by Allan V. Horwitz

Abstract

Reviewed by: DSM: A History of Psychiatry's Bible by Allan V. Horwitz Margaret Leggatt (bio) Allan V. Horwitz, DSM: A History of Psychiatry's Bible (Baltimore: Johns Hopkins University Press, 2021). ISBN: 9781421440705 (HC). 6 B&W photographs, x+ 215 pp. This book is a detailed, thoroughly researched, and comprehensive account of attempts to use the Diagnostic and Statistical Manual of Mental Disorders {DSM) to legitimise psychiatry as a profession with a solid scientific evidence base. As mental health issues are becoming increasingly acknowledged and accepted as distressing states of mind needing to be competently 'treated', understanding the history of what has gone before is important for future progress. Horwitz's book on the pros and cons (mainly cons!) of the DSM should, and hopefully will, help us towards finding better outcomes for those who are labelled 'mentally ill'. The DSM, owned by the American Psychiatric Association, was first published as a small booklet in 1952. By 2013, the manual had been revised to its fifth edition. The first two versions—DSM I and DSM II, published in 1952 and 1968 respectively—presented brief [End Page 144] descriptions of the major mental disorders. However the manual gained much wider recognition in 1980 after publication of its third version—DSM III—an imposing hardback volume of nearly 500 pages. It contained 'detailed and clear-cut symptom lists as well as decision rules that yielded standardized diagnoses', suggesting 'a confident, well-informed scientific grasp of mental illness, a physical embodiment of psychiatry in the scientific image' (p. 64). While the first two DSMs focussed on a small number of distinct entities, DSM III contained nearly three hundred separate diagnoses, many of which overlapped. The vastly greater role of observable symptoms—focussed on patients' current presentation of their problems—distinguished DSM III from the earlier manuals which gave far more importance to the way psychodynamics from past experiences produced symptoms. The changes in DSM III and, also, DSM IVwere not changes to the diagnoses. The major transformations came about as many outside advocates became involved—other mental health professionals, mental health advocacy organisations and feminist groups—making the DSM much more inclusive of cultural phenomena as aspects of mental illness. The extensive descriptive criteria in DSM III also allowed epidemiologists to estimate rates of particular mental disorders in untreated groups, and the enormous approximations that these studies provided became powerful marketing tools for psychiatry and other mental health professions. If clinicians were to live up to their medical credentials they should be able to prescribe medications for a specific disease regardless of the particular circumstances of the person who had it. Treat the disease and not the patient, and if your symptoms weren't recognised as a particular disease, then your insurance wouldn't pay for help. The application of DSM diagnoses to a broader society seemed to indicate that very many more people, not just psychiatric patients, suffered from a mental disorder at some point in life. The DSM III not only transformed the process of psychiatric diagnosis but also thrust the manual into cultural prominence. One suspects that this also became a field day for Big Pharma as more and more people resorted to medications to solve their behavioural, interpersonal, and social dilemmas. Each iteration of the DSM was eventually criticised on a range of different issues, meticulously explicated in this book. For example, after about two decades psychiatric researchers came to the conclusion that there were serious problems with DSM III. [End Page 145] They claimed that the basic characteristics of mental disorders were virtually the opposite of those portrayed in the manual. The categories were 'overlapping rather than discrete, dimensional more than categorical, generalised and not specific, and reflective of a small number of basic processes as opposed to hundreds of distinct conditions' (p. 84). Horwitz explains that even before these issues were taken into consideration, the DSM process would go through two further revisions. Interestingly, comments throughout this book suggest that clinicians were sceptical about the validity of many specific diagnoses. So even though the DSM was 'Psychiatry's bible', the diagnoses seemed to be used extensively as codes to obtain reimbursement from insurance companies for...