The discussion now going on in the American Psychiatric Association concerning the contents of the new Diagnostic and Statistical Manual (DSM III) should arouse the interest of all psychoanalysts since the changes in that document may profoundly affect their practices in the future.
An accompanying article in this bulletin by Dr. Alex H. Kaplan sketches some aspects of the situation as it now stands. But perhaps an examination of some of the historical aspects of the current developments might shed a clearer light on some of the factors involved in promulgating this new document.
The APA Task Force on Nomenclature has been at work on DSM III for several years. Following a discussion of some proposed changes at an open meeting of the membership which took place at the annual meeting of the APA in 1975, a draft of the proposed new DSM III was published in the official newspaper of the APA (Psychiatric News, June, 1975). That draft was accompanied by a statement of the viewpoints of the Task Force and of its chairman and most articulate spokesman, Dr. Robert Spitzer. Other issues of Psychiatric News and of the American Journal of Psychiatry also contribute extensively to the debate.
Last spring in Miami another panel of the APA Task Force on Nomenclature met at which time it was revealed that many changes had been made in the previously published draft and that a new draft was now available, running into hundreds of pages. The account of a subsequent meeting in St. Louis at which this draft was discussed is available in Dr. Kaplan's report.
It is obvious that writing a document such as a taxonomy of mental disorders is a formidable task. However, in this case the difficulties are compounded by the intrusion of theoretical biases.
Dr. Spitzer's words succinctly illustrate what it is that creates the problem for the Task Force: “Those of us who were associated with the effort to remove homosexuality from DSM II never claimed that all mental disorders cause subjective distress, or that if large numbers of individuals with a particular mental disorder object to being so designated, the condition should thereby be removed from the nomenclature. What we have maintained is that if a condition, in its extreme form, is not intrinsically associated with either subjective distress or generalized impairment in functioning (disablity) or obvious disadvantage in coping with the social environment, then it should not be regarded as a disorder. It is most unfortunate that in discussions of this issue, the either is often ignored, thus creating a straw man.” (Psychiatric News, February 1976.)
This attempt at a quasi-behavorial definition of mental disorders runs into the difficulty that a number of conditions which many psychiatrists, and certainly most psychoanalysts, would regard as disorders, do not fit this behavorial definition. The definition having many quantitative and qualitative modifiers, i.e. “extreme form,” “intrinsically,” “obvious disadvantage,” bears careful reading.
The Task Force first attempted to resolve this dilemma of being unable to fit certain disorders into the form which it had by declaring them not disorders. The first diagnosis to suffer this fate was “homosexuality per se” which, as now described in DSM II, does not constitute a disorder. Only if the condition is not egosyntonic is it so, then becoming “Sexual Orientation Disturbance.” A referendum of the members of the APA failed to overturn a Board of Trustees decision to institute this change. It is doubtful, however, that the vote represents the scientific opinion of most members of the APA, but rather their disapproval of the legal persecution of homosexuals. For example, the resolution to introduce this new definition passed the Assembly of District Branches of the APA unanimously, though this is not in fact the opinion of the Assembly. This fact is demonstrated by subsequent votes, including one this Spring which notes objections to many things in DSM III and proposes to develop a liaison committee to the DSM III Task Force, a move which has met with Dr. Spitzer's approval. This is similar to the recommendation of Dr. Kaplan for the A.P.A.
However, it must be noted that the proponents of the changes that were made in the homosexuality diagnosis in DSM II regard their definitions as more than a matter of political expediency, and the first draft of DSM III (Psychiatric News, June 1976) showed extension of the idea that egosyntonicity and adaptational success preclude a diagnosis of mental disorder. At the APA meeting in 1975 the audience at the panel meeting felt (logically, it must be admitted) that instead of homosexuality alone being dealt with in this manner, all the perversions should be. So in the DSM III draft published in Psychiatric News (Spring 1975) in order for a condition like pedophilia or sadism to be diagnosed as a disorder it would necessarily have to be “with distress,” that is, not egosyntonic in terms of DSM III.
In the year that followed that meeting there has been a great deal of protest about this attempted definition, and, as Dr. Kaplan points out, the situation with respect to the diagnosis of perversion is very much in the air. However, a quote from the present draft of DSM III will, at least, illustrate how opinion is shaping up in some quarters.
“302.000 Sexual Orientation Disorder Essential features. This condition is characterized by the following features: (1) sexual arousal is produced by the act or fantasy of homosexual activity; and (2) homosexual fantasies and/or activity are incompatible with the individual's value framework. The patient therefore requests assistance in changing the homosexual erotic stimulus to a heterosexual stimulus.”…. After describing other aspects of the disorder it goes on to quote …
“Predisposing factors … The predisposing factors are not for homosexual orientation per se but rather for the establishment of fixed value systems that do not sanction homosexual orientation. Clinical experience suggests that threatened loss of loved ones who cannot accept homosexual orientation, or early exposure to authority figures who condemned homosexuality might be important predisposing factors.” Then further on:
“Operational criteria for sexual orientation disorder …
“C. The patient seeks change in sexual orientation from homosexual to heterosexual. The therapist, after assessing the value framework and the total adaptive capacity of the individual, agrees that it is in the service of optimal adaptation for change in sexual orientation to be attempted rather than change in value framework.”
It takes little imagination to see the logical extensions of this failure to view mental disorders from the viewpoint of their internal structure and to recognize that the function of defense is to render even serious psychopathology egosyntonic, adaptive and nondisabling. As one could expect, in those conditions in which there are the least behavioral manifestations there are the greatest difficulties in conceptualizing the disorder in DSM III. Thus, concerning personality disorders Dr. Spitzer has expressed himself as follows: “While one may argue that the personality disorders are an exception, on reflection it is clear that it is inappropriate to make a diagnosis of a personality disorder merely because of the presence of certain typical personality traits that cause no subjective distress or impairment in social functioning.” (Psychiatric News, January 1974.) Similar difficulties attend the diagnoses of, and differentiation of, neurosis and psychosis and indeed the diagnosis of neurosis “per se” may be lost entirely.
Dr. Spitzer has stated that these changes in nomenclature have no practical significance other than to promote rigor of scientific thought, since all persons consulting psychiatrists are at least “with distress” if not disabled, and so the nomenclature still retains diagnostic categories under which to treat any person who presents. In fact, the changes serve to disaffiliate psychiatry from social stigmatization of those people who are satisfied with their own functioning and do not run into any difficulties with others. In other words, the scientific definition possibly has a subtle civil libertarian political slant. Also, aside from the absurdity which allows so many severe nosological entities to depend on egosyntonicity and successful adaptational camouflage for their diagnosis, Dr. Spitzer's position is a serious weakening of the stance of psychiatry in the current discussions going on with respect to psychiatric benefits and of psychiatry's position under proposed National Health Insurance. The logic of the position is not so far from stating that possibly psychiatric efforts should be directed toward making any condition egosyntonic; that social stigmatization is, in fact, the ill, and that mental disorder is a myth. The quote above concerning sexual orientation disturbance is close to this position.
Practically every issue of Psychiatric News carries reports of the advocacy of such positions. It is supported by important segments of psychiatrists, many influential in the National Institute of Mental Health and the Community Mental Health systems, who contend that there are no true mental disorders, only physical ones such as the psychoses, which psychiatrists should treat, and that all other psychiatric problems are merely “life problems”, more economically and efficiently handled by relatively unskilled counselors. The APA has thus far withstood the pressure of these groups. In the projected DSM III we see their influence.
However, the situation is not totally dismal. The Task Force of the APA has truly been interested in input from a wide variety sources. The Assembly of the APA has recently established such a liaison for input and the different branches of the American Psychiatric Association possibly may establish similar working groups. Dr. Kaplan has a similar proposal by which the American Psychoanalytic can participate.
It should be noted, however, that DSM III eventully must come before the Assembly of District Branches of the American Psychiatric Association, which probably will be the body that says yea or nay as to its acceptance. Psychoanalysts who wish to have an input into the document can most efficiently do so by maintaining contact with their District Branch Representative to the Assembly of District Branches. It is possible, by 1979, with the speed of present reorganizational change in the APA, that this individual may be the one who will actually vote on the acceptance of the changes. The members of the Task Force have stated their desire to write a document which will be acceptable-and in fact must be acceptable-to the majority of this most representative body of the American Psychiatric Association.
—Oscar Legault