DSM-5

Prompted by adverse coverage greeting the publication something called DSM-5, the fifth version of a diagnostic and statistical manual for mental illness, thought to get a copy and take a peek myself. But, as it turned out, DSM-5 was a hefty tome clocking in at around £80, a bit strong for a passing interest, so I thought I might do better to get a book about DSM-5 rather than the thing itself and, luckily as it turned out, lit upon 'Saving Normal' by one Allen Frances, not previously heard of. An example of the value-add of the Amazon offering, over and above the book shop which I would not have got to for this particular purpose.

'Saving Normal' turns out to be a decent bit of popular medicine, explaining the background to diagnosis and classification of mental illness and going on to explain what is wrong with DSM in particular and psychiatry US style in general, this from the chap who led the team which gave us DSM-4. His genial and easy going style makes for a mostly easy read, although I found it jarred a bit at times and I expect that he has not been too careful about checking some of the details. But a story which will be interesting to those with an interest in shrinkery - and a useful learning experience for those who think that the American way of health is the right way. Cameron & Co. should take note - although one rather despairs of their ever doing so.

He identifies various things which have gone badly wrong and which could be quite easily put right if the political will was there. He also goes so far as to say that there is a bigger problem with legal drugs than there is with illegal drugs although not quite so far as to say that illegal drugs should be made legal.

One: stop drug companies from advertising their products direct to the public, thereby prompting them to think that they have this or that disease and to ask their hard pressed doctor for this or that medicine. Something which is not allowed pretty much anywhere else other than in God's own country, that is to say in the US. Going further, loosen the grip that drug companies have on the medical profession.

Two: change the health insurance company rule which says that they will  not pay out for a visit to the doctor unless the visit results in a prescription. A rule which had the good intention of discouraging unnecessary visits to the doctor but which probably does more harm than good. Going further, encourage doctors in general to take more time over diagnosis and general practitioners in particular to refer rather than prescribe. Psychiatry is difficult and best left to specialists.

Three: tighten up the classification criteria in DSM which presently encourage the classification of people who are well as well as that of people who are ill. Try and get fashions in diagnosis - like that, for example, for autism - under better control. Going further, find a proper home for the DSM. The APA (American Psychiatric Association, see http://www.psych.org/) is clearly not up to producing a manual which is carrying so much weight. And stop using a DSM diagnosis (or lack of one) as such a big driver in decisions about education, support and care.

Various other snippets along the way.

For example, it has been ruled unconstitutional (in the US) to execute people who are dim, with some kind of an IQ test being the test for dimness. So we have the slightly unsavory spectacle of IQ testers determining the final fate of someone who has murdered someone or worse. A determination which might hang on a result falling a point or so either side of a necessarily arbitrary threshold on a 200 point scale. Not sure how you get around the strong incentive to fail such a test.

Interested to learn that DSM started life with the US military, concerned with mental health aspects of combat in the second world war. And full of appropriately trained expatriates from Central Europe.

Frances is a big believer in process and his DSM-4 was very process driven. Interesting to me as the IT industry fell in love with process at about the same time, in the eighties and nineties of the last century. We really believed that it was possible to replace skill and flair by tick boxes - which to some extent it really is. The trick is not to try to push it too far.

Frances is also reasonably pro-Freud. A stance with which I agree because I think that his style, if not his detail, will have its day again when the neurologists have run their course with their neuron models on their big computers.

And he is very pro-psychiatry. He might spend a lot of time in his book knocking present goings on, but he also spends some quality time at the end reminding us that psychiatrists also do a lot of good, mending a lot of lives which might otherwise remain badly damaged.

PS: appropriately, a psychiatric fragment in an otherwise routine office dream. As I woke this morning I had this revelation, blinding light even, that in the course of psychoanalytic work one could work away on some fascinating facet of someone's personality, only to discover that it was a dead end. Cute but without consequence; an appendix of the mind as it were, a relic of evolution. Large computer programs are often full of such things. In the cold light of day, the light is not quite so blinding, but I still think the guts of the revelation might be true. Interesting even.