Joel Paris

I have a number of books written in the 80s and 90s critiquing psychoanalysis from the perspective of Freud’s scientifically outdated theory of mind and his misrepresentation of his own clinical practice. This is a book written in the 21st C which takes those ideas as givens, and looks at psychiatry as presently practised in a post-Freudian world. Reminded me of The God That Failed, a book to which Paris refers as he looks at Freudianism as a parallel case to that of Marxism, although the latter had plenty of life in it when TGTF came out compared to the status of psychotherapy even in 2005 when Paris’s book was published. But I sensed that Paris needed to come to terms with the implications of science-based medicine: that one must abandon practices whose efficacy cannot be objectively demonstrated.… (lisätietoja)

Dear Dr. Paris,

Get over it.

That instruction is one that no competent therapist would use to a client. But it's what Joel Paris seems to be saying to his patients with this book. I bought it because it claims to be a guide to the American Psychiatric Association's Diagnostic and Statistical Manual, Fifth Edition ("DSM-5") -- a thousand page tome full of minutia required to diagnose psychological conditions. The DSM-5 is so big and bulky that it genuinely requires a guide.

What it does not require is a book that should be titled I Hate the DSM-5, Make It Go Away! Wa! Wa! Wa! Wa!

This book is not a guide. It has a few summary comments about some of the conditions in the DSM-5. These are not reliable. For the one I know best, autism spectrum disorder, the overview basically boils down to, "There is nothing wrong with most of these people." Well, Dr. Paris, you can call it autism, or you can call it mass delusion, or you can call it FGHGHGitis for all I care, but the people who have it are still better off for being granted proper interventions. Introversion, contrary to Dr. Paris, is not autism, and autism is not introversion -- some autistics are very outgoing; they just make a lot of social mistakes.

Similarly ADHD. Dr. Paris thinks it is over-diagnosed -- but if someone can't concentrate, and ritalin makes it possible for that person to concentrate, isn't it better to give the poor person ritalin than say "Stop fooling around and concentrate"?

Much of what Dr. Paris is arguing is that this is all the result of Big Pharma wanting more diagnoses so it can sell more drugs. But there are no drugs for autism, and very possibly never will be, so why does Dr. Paris think that that category is being expanded? Because it's "fascinating." "Fascinating" to have to care for an adult who can never tie his shoes or use a bathroom? If data supports Dr. Paris's conclusions, it's good; otherwise, it's to be waved away. That's not science; it's politics.

Or take the procedures used by the work groups to try to reduce industry influence. Dr. Paris, who deplores industry influence, also deplores when "the rules were stretched in a way that reduced... industry influence" (p. 22; italics mine). So which way will you have it, Dr. Paris? Is reducing industry influence good or bad?

On p. xvi, we read that "clinicians... prefer to make diagnoses intuitively" rather than based on hard rules -- rules being what the DSM-5 supplies. This is very likely true. It is not, however, a reason to dislike the DSM-5. It is a reason to get a second opinion from a clinician who actually knows how to do a proper diagnosis.

It will perhaps strike some as ironic that every criticism Paris levels -- that the DSM criteria are not based in sound biology, that diagnoses overlap, that there is too much co-morbidity (that is, too many people who are diagnosed with multiple conditions), that industry influence is too great, that the process is too complicated -- is acknowledged by the editors of the DSM-5, and discussed at length (a good book for this purpose is Regier, Narrow, Kuhl, and Kupfer, editors, The Conceptual Evolution of DSM-5, which is at least twice the size of Paris's book and correspondingly detailed). Two of those editors headed the DSM-5 task force, and they know that the DSM still has problems. But their whole goal is to solve them.

They have not succeeded. They know they have not succeeded. Indeed, some of their proposals for improvement were slapped down. And, yes, in some places, the DSM-5 is worse than what came before. But most of it is better, and they're still working on it. At least the DSM editors have a program. Dr. Paris seems to have nothing except a desire to go back to 1979, before the DSM-III (which set the format of today's DSM-5) came out.

If you truly want a full-throated attack on the DSM-5, Dr. Paris has edited another book which is arguably better, Making the DSM-5: Concepts and Controversies. If you read my review of that volume, you'll find that I have the same complaints about it as I do about this book. But at least it doesn't pretend to teach you how to use the DSM-5. This book, from its title down, gives an utterly wrong impression of its purpose. Most clinicians, I think, will see through that. But I pity the patients of those who do not.… (lisätietoja)

Firing a full broadside in the wrong direction is a great way to cause civilian casualties.

Sadly, that is what this book is guilty of. From the title, you'd think it is a discussion of how the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual (known as DSM-5, and often called the "psychiatrist's Bible") came to be. After all, there were a lot of controversies. For example, the DSM-5 proposal for the so-called "Personality Disorders" was voted down and that section left untouched. I really wanted a book that would discuss all these difficult issues and how they were decided.

But that's not what this book is about. It's an attempt to overthrow the whole modern model of psychiatric practice by taking aim at the diagnostic tool.

Yes, psychiatry does have problems -- too many pills, and too few tests to absolutely say whether someone has a condition or not. But that isn't the DSM's fault! It's the fault of politicians, for not funding research, and of the pharmaceutical industry, for trying to give everyone pills rather than find a real cure. The editors know this; the second essay, John Z. Sadler's "Considering the Economy of DSM Alternatives," is aimed directly at the so-called "Mental Health-Medical-Industrial Complex."

But before you can throw out both baby and bathwater, you'd better at least have started adoption proceedings on another infant. The contributors to this volume point out, correctly, that we don't have a real, verifiable, repeatable model for diagnosing mental illness -- you can't draw blood and say someone has schizophrenia, e.g. But in the absence of that, you have three and only three choices: You can diagnose conditions based on symptoms, you can let clinicians do whatever they want, or you can say mental disorders don't exist.

In case the editors haven't noticed, mental disorders do exist. And letting clinicians do whatever they want has resulted in forced sterilizations, random imprisonments (calling a prison a "hospital" or "asylum" doesn't do anything about the lock on the door!), and complete failure to help people.

So: Of the available alternatives, the DSM-5 model of categorizing conditions based on symptoms is the best. Is the DSM-5 perfect and finished? No; that's why research is continuing, toward what will eventually be DSM-6. DSM-5 isn't all it could be. But it's better than DSM-IV or DSM-III, and vastly better than DSM-I and DSM-II, which didn't even bother with symptoms or defining mental disorders!

Which clearly doesn't make any difference to the authors, who are willing to get things flatly wrong if it advances their argument. Their only mention of autism, e.g., is to complain that the definition has been broadened so that it could potentially include all eccentrics. No, it hasn't; it requires a specific list of symptoms -- and the broadening of autism can't be blamed on the pharmaceutical industry, because, try as they might, they haven't found a pill to cure autism. (Thankfully, since those of us with autism don't want to be cured, and many of us have gifts that society needs.) Or, again, one author says that people have been complaining all along about the way the DSM-III, DSM-IV, and DSM-5 does things -- and cites three works, all of which he authored or edited. Glad to know he agrees with himself; I'd be a lot more impressed if he could get someone else to go along.

Not every article is bad. Whooley and Horwitz's "The Paradox of Professional Success: Grand Ambition, Furious Resistance, and the Derailment of the DSM-5 Revision Process" is a fairly balanced look at how the DSM-5 Task Force's proposal for a more dimensional psychology -- which is surely the way the field should be moving -- has run into problems. But this is something of an exception in a book that is otherwise largely false to its title.

I've been a victim of psychiatric incompetence. But the fault did not lie in the DSM-5; it lay in other areas. This extended screed was a real disappointment. If the authors want to change something, they should try to come up with the research needed for reform, not sit in their corners saying, "I won't, I won't, I won't."… (lisätietoja)