Saturday, February 20, 2010

Sally Satel and DSM-V

See Sally Satel's article in Wall Street Journal 2.19.2010 Prescriptions for Psychiatric Trouble

OK, Dr. Satel, it ain't perfect, but it won't get better unless we keep trying. Dr. Satel gives in to the temptation to take pot shots and gives no praise to the latest effort by the American Psychiatric Association to classify mental, behavioral, and emotional problems and offers no suggestion whatsoever of how we might do better.

She criticizes the new Psychosis Risk Syndrome claiming that "a diagnosis believed to foreshadow a full-blown psychotic illness has the potential to be highly stigmatizing." Is not prognosis a major task associated with diagnosis for physicians? And who has stigmatized "full-blown psychotic illness?" Perhaps Dr. Satel herself has done so. Society stigmatizes psychiatric diagnoses. Don't shoot the messenger, Dr. S.

Dr. Satel goes on to say it might be "especially unfortunate if the labeled individual does not even go on to develop such and illness." That's like saying it is unfortunate if someone involuntarily hospitalized because of suicide risk does not commit suicide. I say it's very fortunate if the person so labeled does not go on to develop the illness, especially if the label leads to intervention that plays a role in altering the course. And speaking of stigma, note that Dr. Satel has substituted the pejorative term "label" for diagnosis or classification. So diabetes is a diagnosis, but "Psychosis Risk Syndrome" is a label?

Dr. Satel calls "stunted sexual development" a Freudian concept?  Does she mean "psychosexual development?" Even Freud did not refer to it as "stunted." Freudian theories have certainly failed to meet scientific muster, but Dr. Satel seems to miss the point that before DSM-III there were no diagnostic criteria based on phenomena, just descriptions. And terms like neurosis implied unproven Freudian causes.

Major depressive disorder is not, as Satel claims, the sole designation for "pathological depression," which in fact encompasses numerous disorders such as Dysthymic Disorder, Adjustment Disorder with Depressed Mood, and others. She asks, "How do we know it is not a normal reaction?" Read the criteria doc. It's spelled out clearly. Dr. Satel may also have failed to read the Cautionary Note at the beginning of the DSM. I guess if you're suffering but she doesn't "know it's not a normal reaction" Dr. Satel will refuse to help you.

Dr. Satel rightly suggests that the "causal mechanisms" of mental illnesses might be staggeringly complex, but she fails to state that such mechanisms have yet to be defined at all. Would you have us wait until we know the mechanisms before we classify the disorders -- or treat the patients who suffer from them?

Dr. Satel criticizes the manual for failing to divide the diagnoses "as tidily as the manual implies,"  because, for example, the same patient might suffer from bipolar disorder and ADHD. Perhaps she would have us give up. Just call them all crazy and lock them away. Why might someone not have 2 or more psychiatric disorders? You can have fleas AND lice.

So Dr. Satel, we might take a few steps back, but DSM-V will very likely move us forward at least a little.


  1. Readers interested in the DSM might enjoy this longer, more detailed article.

    Sally Satel

  2. I don't know whether you'll "enjoy" the article, Satel's review of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder by Allan Horwitz, but I recommend it to anyone watching the evolution of DSM:

    I hope by reading Dr. Satel's excellent review I will get the message without reading the book.