During the 1900s, the insanity standard evolved. The Durham Rule was created in the 1950s. Durham tried to take into consideration psychiatric and medical standards for insanity. This proved unworkable. The brand new DSM-I had been published in 1952, listing 106 mental disorders. Defense attorneys began trying earn their clients acquittals if they had any of the diagnoses found in the DSM-I. It did not take long for the reaction to the highly liberalized Durham rule to come under fire. Twenty-two states rejected the Durham rule outright. In 1972, a panel of Federal Judges discarded the Durham Rule. They adopted the standard created by The American Law Institute (ALI). The ALI standard allowed for a more flexible interpretation of understanding than simple cognitive knowing. The ALI model also avoided use of diagnoses found in the DSM-I, and the later DSM-II, as a legal basis for insanity. The DSM-II increased the number of diagnoses to 182, and dropped use of the term “reaction” as a diagnosis, because that implied causality. About half the states retained the M’Naughten Rule and half adopted some variation of the ALI standard. The Federal Court system adopted the ALI standard for establishing insanity.
The DSM-III was published in 1980. It was considerably different than the two previous versions. It added more detail, along with algorithms for making differential diagnoses. There was a five-axis matrix on which to report a diagnosis, including something called the Global Assessment of Functioning, or GAF. The DSM-III contained a staggering 494 pages with 265 diagnostic categories. When the DSM-IV was published in 1994, it listed 297 disorders in 886 pages. During all these iterations of the manual, some diagnoses were removed, and new ones added. Some had their names changed. Illnesses became “disorders.” Earlier versions listed homosexuality as a mental illness or disorder. The committee voted to change that to “egodystonic homosexuality.” Later it was removed altogether.
DSM-5 (they have dropped the Roman numerals) was released this weekend, but don’t know anyone who has actually seen one. This version, unlike all previous versions, was conceived in almost total secrecy. There was a public comment period, but all members of the committee had to sign a non-disclosure agreement. As a result, there has been no transparency as was the norm in the past. What we know of this new diagnostic manual is limited to what the American Psychiatric Association has released piecemeal. The new version has 947 pages and over 300 diagnoses.
Where is this going? My interest is in the forensic psychology aspect of the new manual. Previous versions of the DSM have been criticized for lack of validity. Based on what has been released about the manual so far, it appears the newest version suffers from the same flaw. I have observed problems with inter-rater reliability, when using any version of the DSM. In other words, if ten psychologists and psychiatrists examine the same patient, how often do they come to the same diagnosis? Lack of agreement on any given diagnosis is far more common than the public…and lawyers….ever suspected. I have attended countless staff meetings where a half-dozen experienced psychologists and psychiatrists argued heatedly whether a patient was one thing or another diagnostically. They all missed the main point. The question they should have been addressing was whether the defendant was competent to stand trial and criminally responsible. It made no difference whether the defendant had a personality disorder or not. Folks, it doesn’t matter what the diagnosis is. The legal criteria are not found in any diagnostic handbook.
...
Problems with the new DSM-5 go far beyond whether it should be accepted as the definitive diagnostic manual by the legal system. Two weeks ago, Thomas R. Insel, M.D., Director of the National Institute of Mental Health (NIMH), delivered a sharply worded statement saying the NIMH would no longer fund research based on the DSM-5. His criticism is the same as mine,
“The weakness” [of the DSM-5] “is its lack of validity….Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.”
Adding his voice to those criticizing the DSM-5 is Dr. Allen Frances, editor of DSM-IV, and Dr. Robert Spitzer, editor of DSM-III. Spitzer wrote an open letter to the DSM-5 committee complaining about forcing task force members to sign a non-disclosure contract, which flies in the face of proper protocols for scientific or medical projects. The DSM-5 staff rejected Drs. Frances and Spitzer’s complaints about lack of transparency, blaming their motivations as the fact both are still receiving royalties for their work on the previous editions.
In a press release three years ago, Canadian Medical Associaton Journan (CMAJ), in collaboration with the Journal of the American Medical Association (JAMA) published an article highly critical of the DSM-5 task force and its operation. The article included the following:
Some critics of the DSM process express other concerns in addition to matters of transparency. It’s been pointed out that about 70% of current task force members have ties to the pharmaceutical industry, up about 14% for DSM-IV. A study of an earlier edition of the manual found that ties to the drug industry are particularly strong in working groups focusing on diagnostic areas in which drugs are the first line of treatment (Pscyhother Psychosom 2006;75:154–60). For DSM-IV, all of the members of the working groups for mood disorders and “schizophrenia and other psychotic disorders” had ties to drug companies.
“We recommended that they limit the number of people on these working groups with industry ties, making them a minority so they won’t dominate,” says Sheldon Krimsky, a coauthor of the study and an adjunct professor in the Department of Public Health and Family Medicine at the Tufts School of Medicine in Medford, Massachusetts. “But that hasn’t happened yet.”
As far as I have been able to determine, nothing changed since that memo. Talking with both physicians and psychologists, I hear little else but skepticism that the new DSM-5 is driven more by economics than science.