Number Of Ways To Go Nuts To Increase: DSM-V

Here are the official number of ways you can go nuts, according to the peer-reviewed Diagnostic and Statistical Manual of Mental Disorders.

Diagnostic and Statistical Manual of Mental Disorders

The DSM-I started in 1952 with just 601 ways that your mind could go awry. A committee of folks from the World Health Organization, the US Army, and other psychiatric professionals gathered together, pooled their experience, and decided that these 60—and only these 60—diagnoses meant you were mentally ill.

By 1968, these experts changed their minds. They announced, “The Science was not settled” but implied that it now was when they published DSM-II, discovering three times as many more ways to end up under care, putting the total at 182.

After their yearly convention was stormed by angry homosexual activists in 1974, the committee changed their minds and dropped one major diagnosis, leaving just 181 in DSM-II (amended) . Before 1974, medical professionals assured us that “ego-dystonic homosexuality” was a (treatable) disorder. From 1974, it was reclassified as a “sexual orientation disturbance.”

Just six short years later, in 1980 the medical community again admitted they were wrong before and said now that there were 265 mental maladies, and not a mere 181 as previously thought. These went into the DSM-III.

“Not so!” said the reconstituted DSM-III-R committee of 1987, “There are 292 misconfigurations of the mind. We’re not sure how those who came before us could have missed so many diseases.” This was mostly okay with the folks who met again in 1994 to put out DSM-IV: they only added a bare five newly discovered disorders.

The last committee met in 2000 and were either not imaginative enough to figure any new disorders. They could only bring themselves to reclassify and reword. But they felt that had enough authorial input to rename the book to the DSM-IV-TR

Now, the DSM-V is scheduled to be released in 2013. Given the increase we have seen from previous editions, it is rational to suppose that the latest work will detail many new diseases previously unknown to medical science. How many more?

The bottom dashed line is a crude statistical extrapolation. The upper dashed line uses information from Tim Black’s Spiked paper “Are you shy? Then you have a mental disorder.”

Wikipedia counts 297 diseases in DSM-IV, but Black asserts that by 1994 there were already “384 mental ailments (plus 28 ‘floating diagnoses’).” That’s a huge discrepancy, likely the result of counting sub-diagnoses separately. But if he’s right, then we can guess that there will be at least 384 entries in 2013.

About the increases, Lisa Appignanesi of the Guardian isn’t happy about this:

Over the last 40 years The Diagnostic and Statistical Manual of Mental Disorders – the bible of the psychiatric professions – has spawned more and more diagnostic categories, “inventing” disorders along the way and radically reducing the range of what can be construed as normal or sane. Meanwhile Big Pharma, feeding its appetite for profits and ours for drugs, has gained an ever greater hold over our mental and emotional lives, medicalising normality.

Black concurs and gives us an example of the newly discovered “hoarding disorder”:

In an incredible bit of insightless prose, we are told by DSM‘s recent consultation document that, ‘The symptoms [of hoarding disorder] result in the accumulation of a large number of possessions that fill up and clutter active living areas of the home or workplace to the extent that their intended use is no longer possible’.

The numbers are also unclear because the DMS-V has been wrapped in secrecy: task force members were made to sign a nondisclosure agreement which forbade them to speak about the process. In a bit of unintentional hilarity, Robert Spitzer, the head of the DSM-III task force, said

When I first heard about this agreement, I just went bonkers. Transparency is necessary if the document is to have credibility, and, in time, you’re going to have people complaining all over the place that they didn’t have the opportunity to challenge anything.

I propose that Spitzer’s outburst be classified as dissonant peer-review neurosis. Other entries are welcomed.

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1As of 12 September 9:00 AM PST, this post is tentative. I am using data sources which give contradictory information, and so I ask you, my loyal readers, for help in firming up the numbers, at which point I will update the picture. My numbers were retrieved from Wikipedia (yes, I know).

This post is a follow-up to “Are 40 Percent of Europeans Mentally Ill?”

24 Comments

  1. They take a vote on what is a mental disorder. Can you imagine medical doctors taking a vote to decide if cholera is really a disease? Homosexuality used to be a mental disorder, but they took a vote and decieded it was perfectly normal.

    Speaking of going bonkers, I recommend the Bonkers Institute without any qualification whatsoever. Go here. http://www.bonkersinstitute.org/index.html

  2. There is no more fitting source for a tally of mental disorders than dear old Wikipedia. It’s commitment to truth, justice and the American way – oh, wait, that’s something else. At any rate we have always been able to trust Wiki-baby and thus once it says something, that’s it! Unless it changes it’s mind, and then that’s it! Unless it changes it’s mind again. Hmm. I see a problem.

    Accordingly, I nominate “Wikiphrenia” for membership in the DSM hall of fame, and anxiously await being filled in by Wikipedia as to all this newly discovered disorder entails. Plus, pharmaceuticals owe no special thanks for this opportunity to pad their stable of formulations. It is all part of our snappy service.

  3. This has been going on for a long time, and there are serious dangers. For an early warning, see

    Elinder L. (1997), Läkartidningen [Journal of the Swedish Medical Association], 40: 3391–3393.
    at
    http://www.informath.org/apprise/a6400/b33.pdf

    Elinder jocularly identifies several new disorders: “dysfootballia”, an inability to play football (a neuro-orthopedic disability), “dysinternetia”, the inability of the middle-aged to understand the Internet (a neuro-geriatric disability), “dyspiania”, the inability to learn to play piano (a neuro-musical disability), etc.

  4. The Guardian would do well to refuse comment on matters psychological and psychiatriatic, considering the pretzel-shaped logic they’ve regularly employed in their editorial writings.

    All my mental disorders are weather / climate related, save those which are not. I’ve been anxious over albedo, perplexed over paleoclimatology and severely psychotic regarding psensitivity. Did I say albedo? I meant libido. I get those confused.

  5. @ Ray. Further your voting comment. When you take your car in for repair would you let several mechanics “vote” on what is wrong? Or the next time you paint your house, do all the town’s painters “vote” on the colors? Opportunities for irony and satire abound. What fun.

  6. One would think our host suffers from DSM-phoria.

    Once upon a time, DSM-IV was available in-full online. No more. There must be a mental disorder that describes the wish for secrecy.

    Mental disease is obviously spread by infectious memes which were allowed to spread during past Republican terms. O undoubtedly has a plan to fix that.

  7. You guys may be missing the whole point of this – increasing business. If even 5% of those newly discovered to be afflicted can be enticed to treatment maybe the psychiatric fraud can be extended another generation or two.

    A treatment instead of a treat.

  8. Refinements in categorization do NOT reflect increases in the number of things categorized. This is a very fundamental, misleadingly inaccurate, flaw with the premise presented here.

    This is analogous to belt ranks in martial arts increasing (e.g. many years ago I recall four belt ranks separating white from black…and some schools now have something like nine new intermediate ranks, each one requiring a testing fee to gain the next rank). Coin grading used to have two grades (new & used) which gave way to a small handful of grades to about eight grades for circulated coins now; for the best grades, almost uncirculated (AU) then uncirculated (Unc), which gave way to “Mint State” (MS) …. which has long since been further subdivided into ten such categories (MS-60 thru MS-70). The MS grades are so subjective that it is common for a person to submit a coint to a reputable grading service multiple times & achieve an increased grade (perhaps worth $100s or $1000s). These coin grades reflect the strength of the imagery in the coin as made by the die. With copper coins, color (and the shades vary from bright gold/red to very dark brown) is an additional factor superimposed on the usual grades associaed with all coins.

    This blog wrongly suggests the number ways to have a mental illness increased. That is just as untrue as applying the same deductive approach to conclude that more martial art skills are required to gain black belt (i.e a 1st degree black belt today has more skills than one a decade or two ago), or, there are more collectable coins, etc.

    A number of mental health issues tend to pretty much always occur together (e.g. narcissism & various types of neuroticism tend to occur in very predicatable & particular behavior patterns [they’re “co-morbid”]) — analogous to grading copper coins in the MS categorization coupled with the color grades. The creation of color & MS grades does not increase the types of issues with coins, it just clarifies the subjectivity hoarded by experts…ditto for the increase in DSM diagnostic criteria (for the most part). Thus, some mental health conditions [like coins] are described by dominant features that, to outsiders, appear like new & arbitrary –and [wrongly] separate & distinct– illnesses.

    EXCEPTION: The discussion about activism altering diagnoses (gender identity/orientation) is accurate — homosexuality is possibly the first, and one of a very tiny number at any rate, of mental issues that have been removed from the DSM via activism by those “afflicted.”

    As someone noted, the increased categorization & other activist-based adjustments do correlate with business/income generation via some readily intuited, and some not, contrivances …. unfortunately.

  9. Ken,

    Your criticism is well received. It could be, and it is probably true, that new, heretofore unknown mental diseases are being found. And it could be that clarifying that one disease is really two, or three, is also likely. But so many new diseases? And so many new clarifications in such short time periods?

    Let me clarify. Because the number of diagnoses are increasing, and are likely to increase, means at least several important things: (1) That the sciences of psychology and psychiatry are far from settled; (2) That treatments recommended today can be rescinded tomorrow—and not just rescinded but labeled harmful, whereas before they were helpful (see the Bonkers website recommended; especially the thorazine treatment ads); (3) That one thing can be a disease today and, by vote, be labeled normality tomorrow; (4) That one disease—neurosis—is or isn’t depending to which school one subscribes; (5) That wide variances in diagnosis can be had (e.g., different docs using the same SCID often will diagnosis the same patient differently).

    The suspicions are that some of the diseases of the DSM aren’t, and that, even worse, it will be easier to classify people as suffering from a given disorder.

  10. I just went to the DSM5 site DSM5 site because I think Mr. JH is becoming more and more like Max Goldman. We all know that early identification is extremely important. So I visited the tab of personality disorders (under Proposed Revisions) in the hope of finding helpful information about treatment for grumpy old men.

    Gee, those criteria for the personality disorders are quite serious. I would say that people who meet those criteria are mentally ill. I am not a mental health professional though.

  11. Briggs,

    Your comments to my comments are, within limits, correct.

    My point (which I hope was clear) was/is that much of categorization reflects parsing “shades of grey” & other “colors” into discrete categories. I tended to focus on the positive; you focused on the negatives…in so doing presented a skewed perspective sans the qualifiers.

    I suspect the proliferation of DSM illnesses/diagnoses is significantly driven by medical insurance companies. Their interest & pressure to move patients out of hospitals (e.g. post-surgical care, etc. etc. etc.) and out of all types of therapy (e.g. post-injury physical) to save money is well known. I would wager that the categories being developed or refined are dominated by those that are readily identified on a simple Pareto Chart of significant insurance factors. And not that insurance companies are exerting any particular direct influence…people tend to respond to pressures & constraints in predictable ways as if they just want to please.

    Ominously, this is [if true] analogous to how NAZI values influenced the types of findings German psychologists found leading to & reinforcing various eugenics policies.

    As M. Twain put it, ‘History might not repeat, but it rhymes.’

  12. Ken,
    Differentiating within shades of gray, suggest assignment of numbers to treatments – diagnostic events and then disallowing some of these coverage. So whereas a diagnostic effort or treatment series might have been allowed if directed toward the more inclusive gray, some of the subtle shades may be disallowed.

    Differentiation also supports the evolution of whole new cadres of specialists along with the inevitable acronyms which along with their pharmaceutical responses will shortly appear on the NBC Nightly News.

    DOA just doesn’t do it anymore. Too bad.

  13. It is the good old: “If all you have is a hammer, everything becomes a nail.” syndrome.

    The makers of DSM don’t have a real job to do and couldn’t do it if they did. All they can do is make up diagnosis out of thin air. I suspect they have a tecnobabble phrase generator into which they inserted their 500 or so favorite words and 100 or so of their favorite prefixes and suffixes. It then prints out, randomly, three and four word sequences appropriately amended by randomly selected prefixes and/or suffixes. They look at that list. Then, if they find a phrase they haven’t seen before, they make up symptoms matching the phrase. The result is then scheduled for the next release of the DSM. Following that, they take a week off, at taxpayers expense, to congratulate themselves for doing such a fine job.

    This leads to another good old principle: “You get what you pay for.” Unfortunately, when you pay at the point of the government’s gun (taxes) you don’t necessarily want nor need what you get. Reality fades further and further into the mists of a forgotten time. Alice’s world of Through The Looking Glass looks real and rational by comparison. Humpty Dumpty would blush at the use of words today.

  14. Aha!!! Speculating that medical insurance is a factor in the proliferation of diagnostic categories…and the Wall Street Journal (WSJ) has an article on just that, noting that a new federal law is about to expand the number of medical-insurance codes dramatically. The codes are used by hospitals and doctors to describe a patient’s injury, and apparently the existing 18,000 codes don’t allow them to be specific enough. The new law will result in about 140,000 more codes, according to the report. The WSJ article is at: http://graphicsweb.wsj.com/documents/MEDICALCODES0911/#

    Clearly, code W5922XA is long overdue — that’s an injury associated from being struck (not “bitten,” “struck”) by a turtle.

    The V9541X series, V9542X series, and V9543X series addresses various injuries associated with being struck by spacecraft: collisions, forced landings, crashes — apparently, the medical profession can determine independent of the FAA/NASA if a landing was “forced” vs. a “crash.”

    THAT may be an unintended benefit to accident investigations and insurance payout requirements by the non-medical insurers…who, undoubtedly, will really appreciate the medical insurers saving them the trouble of assigning liabilty for the damaged hardware…. Such as when a turtle astronaut (“turtlenaut”??) is flung when its reentry vehicle crashes thru one’s picture window & then cracks one’s rib.

  15. Ken,
    we have very recent experience with codes. our coverage provides free “screening” colonoscopies. This is where the doc takes a look to see if there’s anything worth doing something about. There is a code for “screeening” and another for “diagnostic” colonoscopy. Diagnostic is where they’re looking for something specific related to a complaint or other external symptom. Diagnostic isn’t free, but subject to a co-pay. Pretty soon there is an anesthesiologist there and a myriad of charges and the co-pay reaches into the upper hundreds of dollars.

    Comes the biil, and our “screening” voyages up the alimentary canal, no gun, but camera, have now become “Diagnostic” and they want money.

    So after an unbelievable run-around from both the insurer and the provider, we discovered that the provider codes all colonoscopies with the diagnostic number, unless there is something about it that makes it more lucrative (a turtle in there) hence a different code. And guess what, both the docs and the insurance company make out better that way.

    The opportunity in miscoding medical events to the mutual benefit of the docs and the insurers is incalculable. Think of it as a giant Wurlitzer theatre organ. “they laughed when I sat down to play.” (Maybe you’re not old enough for that one.) But then out come the stops, the fingers dance over 5 keyboards, the toes perturb the pedals and voila, a slight error here, a slight error there and pretty soon we’re talking billions.

    Nothing new here. Adam Smith said it first:

    “People of the same trade seldom meet together, even for merriment and diversion, but the conversation ends in a conspiracy against the public, or in some contrivance to raise prices.”

  16. Re: diagnostic code proliferation…and specifically the code for being struck-by-a-turtle (which presumably would include being struck by a tortoise, but with 140,000 such codes, it would also seem reasonable to presume a specific code for tortoise strikes independent of turtle strikes).

    At any rate, the author of a legal blog weighed in specifically on the struck-by-a-turtle code — undoubtedly a very significant matter — and had a humerous take on that:

    http://www.loweringthebar.net/2011/09/more-on-the-risk-of-death-by-turtle.html

  17. Ken,
    re: the legal reference.

    If it could happen to Euripides, why not one of us? Is it possible that someone did a Google search of every possible means of injury or death and then went on to assign each a code?

    I am reminded of a complaint from the grade-school teacher wife of one of my classmates ion undergrad school. She had asked her students to prepare a list of all of the things which could be constructed of brick. The subject of the complaint had the longest list. It included cheese sandwiches, ice cream cones, airplanes, blimps, and other things the rest of us might not have thought of. She thought she was being made fun of.

    We wanted to meet the kid.

    Now I know where he went.

  18. Ken,
    The codes have to be the work of summer interns. If I’m ever fool enough to again be an employer, whoever did it has a job and a good one. He/She has to be the type that would be removed from the applicant pool by HR and for that reason alone likely to be a worthy associate.

    Death by turtle is really choice.

  19. Great article and graph thanks! I’m curious if you know how many disorders are in the DSM-V, now that it’s out? The Wikipedia page doesn’t say.

    Cheers,
    Graham

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