Book Review

The Selling of DSM: The Rhetoric of Science in Psychiatry

N Engl J Med 1993; 328:1132-1133April 15, 1993

Article

The Selling of DSM: The Rhetoric of Science in Psychiatry
By Stuart A. Kirk and Herb Kutchins. 270 pp. Hawthorne, N.Y., Aldine de Gruyter, 1992. $39.95 (cloth); $19.95 (paper). ISBN: 0-202-30432-9

Psychiatric nomenclature and diagnosis have undergone dramatic changes over the past 20 years. This was exemplified by the release of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980 (Washington, D.C.: American Psychiatric Press). The manual represented an attempt to move from the more impressionistic diagnostic systems of DSM-I and DSM-II to diagnoses based on specific, objective, nontheoretical criteria. The Selling of DSM by Kirk and Kutchins is a lengthy critique of the profound paradigm shift in psychiatry embodied in DSM-III (and the subsequent revised edition, DSM-III-R, published in 1987). The second chapter actually lays the foundation for the book. Here the authors contend that the transition from DSM-II to DSM-III was motivated not by the interests of science but by lesser matters. The authors assert that DSM-III was a reaction to “psychiatry under siege” in the 1960s and 1970s -- a profession bereft of scientific foundations and increasingly losing its position as a medical discipline. Unfortunately, the authors simply mistake the reason for this shift of paradigm.

After the Clark University lectureship by Sigmund Freud in 1909, psychoanalysis progressively became the dominant theoretical orientation in American psychiatry. Analysis held sway in most academic circles until the introduction of effective pharmacotherapy in the 1950s led to the so-called biologic revolution in psychiatric research. Earlier, though diagnoses were certainly made, diagnostic rigor and specificity were relatively unimportant, since the prescription was largely the same -- psychoanalysis. The match between diagnosis and treatment became increasingly necessary as biologic and other more specific therapies flourished. Methods to increase diagnostic certainty grew out of the necessity of having diagnoses that could be repeated among research centers, not out of a misbegotten desire to “save” psychiatry. Early attempts at making diagnoses reproducible, such as the Research Diagnostic Criteria (among others), led ultimately to DSM-III.

The authors appear to have linked disparate themes -- the problems with the public and professional image of psychiatry and the need for accurate research diagnoses -- to create a myth about the DSM. In doing so they manage to criticize all aspects of the endeavor, at times in contradictory ways. For example, they alternately disparage psychiatrists' lack of diagnostic acumen in the pre-DSM-III days and criticize the later attempts to improve diagnostic precision that led to the new criteria. The piece de resistance is not a part of the book at all, however, but rather a remarkable endorsement by Thomas Szasz, M.D., on the book's cover, in which he extols this “expose of the pretense that psychiatric diagnoses are the names of genuine diseases and of the authentication of this fraud by an unholy alliance of the media, the government, and psychiatry.” This hardly appears to be a scientific appraisal. The writers quote Szasz's statement that “real mental illnesses are abnormalities . . . clearly linked to physiological dysfunction,” without recognizing the absolute necessity of categorical precision in order to make such discoveries.

On the other hand, this is an interesting, though biased, book. If one can ignore the tendency to major in the minors (such as the troublesome issue of homosexuality as a diagnosis and the problem of psychiatrists as expert witnesses in court), there are some strong points. There are quite good sections on validity and reliability, with skillful explanations of why problems continue to plague the diagnostic criteria. These arguments are relevant to DSM field trials and are exemplified by the recently published, somewhat disappointing, attempt to validate the Structured Clinical Interview for DSM-III-R (Archives of General Psychiatry 1992;49:630-36). These sections contain valid criticisms and make thought-provoking reading for anyone interested in the science of psychiatric diagnosis.

As I read the book, I was struck by its apparent ambiguity of purpose. Is it a critique of diagnosis as labeling, of the concept of mental illness, of the “medical model” in psychiatry, of the DSM in general and field trials in particular, or of the “politics of science,” or is there another motive? One need look no further than the authors themselves to discover a vested interest. Dr. Kirk is a professor of social work at Columbia University, with research interests in deinstitutionalization and chronic mental illness, research utilization, service delivery, and labeling in mental health. Dr. Kutchins is a professor of social work at California State University in Sacramento and is described as currently doing work on the prescription of psychotropic medication by nonphysicians. They have coauthored a number of papers in the past. A quick survey of their articles listed in the bibliography of the book is quite revealing. In an article entitled “DSM-III and Social Work Malpractice” (Social Work 1987;32:205-12), the authors state that “DSM-III is not good for social workers,” because of a number of technical and legal dilemmas that social workers find themselves in when using DSM-III. The authors, responding to a statement by Gerald Klerman about DSM-III, write, “These words are not the terms in which dispassionate scientists speak. They are words of a tough warrior fighting to vanquish adversaries in a battle for control over the field of mental health.” Elsewhere in the discussion, however, they say (citing Schacht and Nathan), “They warned that the next step would be the dominance of physicians in the treatment of clients. This situation has not yet occurred, but, if the analysis presented here is accurate, it is inevitable. Social workers have struggled hard to discard the role of psychiatrists' handmaidens; the use of DSM-III is a step back in that direction.”

This is hardly the language of science, but we do appear to have found the real motive behind The Selling of DSM. This book (along with much of the referenced literature by Kirk and Kutchins) is about a sociopolitical struggle for ascendancy in the delivery of mental health services. I doubt that the authors could ever accept the DSM, regardless of the reliability of diagnoses, since to do so would, in their terms, return social workers to a position as handmaids of psychiatrists. This book has something to say to those engaged in psychiatric research (though the critique of DSM-III research can be seen as only an expansion of the authors' published work). Unfortunately, their belligerent political tone obscures the good recommendations contained in this book.

Richard C. Shelton, M.D.
Vanderbilt University, Nashville, TN 37232