Evolution of the DSM, from DSM-I in 1952 through DSM-V 2013

According to Moncrieff, the “modern state has been seeking a solution to the problem of madness since at least the end of the 18th _{century” (2009:51). Major changes in the structure of} mental health diagnosis started to be felt both within and outside the medical field in the 1980s. The American Psychiatric Association Diagnostic and Statistical Manual or the DSM was first published in 1952. Ironically, one of the rationalizations motivating the psychiatric community’s production of the manual was to counter their diminishing status and perceived stigma toward them from the public and the medical profession (Conrad 2007; Moncrieff 2009; Peterson 2008). Revised editions were introduced in 1968 (DSM-II) and 1980 (DSM III). This last publication marks a distinct shift in the medical paradigm from psychoanalytic to biomedical and was revised in 1987 becoming the (DSM-III-R). More revisions occurred in 1994 (DSM-IV), 2000 (DSM-IV Revision), and 2013 (DSM-V).

The DSM III has been described as the means by which mental health professionals legitimized their professional authority to manage mental health issues. Researchers cite the shift from the DSM II’s focus on the psycho-dynamic model of mental illness to a diagnostic model in DSM III (Kirk and Kutchins 1992; Lane 2007). The change originated not because of an increase in knowledge from medical research or studies, but rather from social dynamics, including the necessity of measurable criteria for insurance reimbursement (Horwitz 2002).

This diagnosis-based approach was linked with identifying clusters of symptoms indicating a specific underlying disease such as schizophrenia (Conrad 2007; Frances 2013; Horwitz 2002). The DSM III was revised and became the DSM-III R in 1987, which some practitioners consider “a mistake and a distraction” (Frances 2013:69). At this point, the diagnostic system had evolved into what Allen Frances, M.D., former chair of the DSM-IV (1994) task force, described as the “unwitting tool of drug company marketing” (2013:69).

The DSM-IV was published in 1994 and critiqued by Horwitz and Wakefield for

conflation of normal (for example, the sadness of grief which will over time dissipate) with “true depressive disorders that are not proportionately grounded in social contexts” (2007: 107). They supported further that this medicalization of “normal” emotions prevented legitimate research from discovering real causes and effective treatment for true disorders and legitimate

psychological dysfunction.

The 1990s were significant in mental health treatment not only because of this development, but also for the 1997 Food and Drug Administration Act (FDAMA), which loosened constraints for off-label prescribing. This federal law opened the door for

pharmaceutical companies and their sales representatives to give doctors off-label uses as long as they provided adequate scientific documentation or were engaged in clinical trials for the new uses (Conrad 2007). At the same time, the regulation reduced requirements for the amount of information shared in direct-to-consumer advertising (DTCA) (Corrigan, Kosyluk, Fkuo, and Park 2014; Payton and Thoits 2011). The only countries that permit DTCA today are the United States and New Zealand.

During the 1990s, pharmaceutical companies began to lobby the federal government to include attention deficit disorder (ADHD) under the protection of the Individuals with

Disabilities and Education Act. Lawmakers also cleared the way for families to collect social security supplemental income (SSI) in instances where children were diagnosed with the disorder (Peterson 2008).

Between 1990 and 2000, prescription drug spending tripled in the United States, from $50 billion to $150 billion or more (Szegely-Marzak 2001). In the same timeframe spending on anti-depressant drugs rose 800% (Tanouye 2001). The new ‘atypical’ antipsychotic drug created a 600% rise in the sale of neuroleptics to $4 billion dollars in 2001 (Moukheiber 2001). The success of “atypicals” can be measured in the increased use of antipsychotic drugs in youth in 1992 with 50,000 young outpatients using them; by 2002 the number had increased to 530,000 (Thomas 2002).

Eli Lilly funneled money through the World Psychiatry Association (Rosen et al. 2000) and NAMI (Oaks 2000:14; Silverstein 1999) to mount an anti-stigma campaign. The thrust of the campaign was to advocate “for the elimination of discrimination against people diagnosed with schizophrenia, so long as they are taking medication—by force if necessary” (Mosher, Gosden, and Beder 2013:132).

In what has been suggested was a coordinated tactic, The Treatment Advocacy Center (TAC), originally a branch of NAMI, began feeding the media with stories about the

dangerousness of untreated schizophrenia. This campaign involved disseminating stories about untreated schizophrenia and violent behavior (Torrey and Zdanowicz 1999:27), as well as promoting stories about episodic violence perpetrated by individuals with schizophrenia and bipolar disorder, claiming this accounted for 1000 homicides per year in the U.S. (TAC 2001). The intention was to facilitate legally mandated involuntary treatment of people in their own homes.

It has been well documented that ADHD drugs, such as Ritalin, are often the jumping off point for what becomes a long history of medications for children. Within 10 years, children who had been diagnosed with ADHD also were being diagnosed with comorbid depression, obsessive compulsive disorder, conduct disorder, generalized anxiety disorder, or intermittent explosive disorder, when children express (allegedly) disproportionate or extreme anger during what observers classify as minor incidents (Peterson 2008).

Large pharma has been a part of every major decision and policy direction since the 1980s. The study of stigma has begun to look at the ways in which medicalization has impacted views of mental illness by the general public, those with mental illness, and close friends and family. For example, research has assessed direct-to-consumer marketing by pharmaceutical companies and its effect on stigmatizing attitudes (Corrigan et al. 2014; Payton and Thoits 2011). The insidious and sometimes obvious influence of large pharma further can be identified through the shifting and expanding use of “diagnostic” language within large community studies and surveys.

The difference in approach to disseminating information about psychiatric disorders and medications began to show up in discrepancies among large social surveys, notably the number of participants who would advise against or for taking psychotropic medication (Mojtabai 2009). It began with the General Social Survey, which in contrast to other countries, did not distinguish between different psychiatric medications or conditions. Also the prevalence of direct-to-

consumer advertising increased significantly. The nature of the benefits that these advertisements promote are somewhat vague, as are the side effects (Mojtabai 2009).

Mojtabai concluded it was necessary to develop more targeted and selective public information campaigns so that they could identify the conditions that “merit the use of

psychiatric medications and to distinguish these conditions from self-limited stresses of daily life that not require medication treatment” (2009:1022). Mojtabai had received considerable research funding from Bristol-Myers Squibb Pharmaceuticals. The financial support of medical and academic study by pharmaceutical companies has been viewed as increasingly problematic in terms of study validity and motivation.

The National Institute of Mental Health (NIMH) developed a fully structured interview that could be administered by interviewers. This diagnostic interview schedule was based upon the DSM-III and designed for the Epidemiologic Catchment Area (ECA) studies conducted at five sites in US cities and translated into many other languages (Regier and Robins 1991). Ultimately, it was altered for use in special populations including children (Shaffer et al. 2000).

Other DSM specific interviews and diagnostic instruments are available for community- based research, including the Structured Clinical Interview for DSM-IV (SCID), the World Health Organization-Composite International Diagnostic Interview (WHO-CIDI), and the Mini International Neuropsychiatric Interview (MINI). Various research has relied upon large

community studies to determine population views on mental health issues both in themselves and others, for example, the US General Social Survey (GSS) 1996, 2006 (Pescosolido et al 2008, 2010; Thoits 2016).

According to Conrad, the incorporation of diagnostic language into surveys has the potential to “medicalize more of life’s problems and overstate the existence of untreated

psychiatric ‘pathology.’ Findings like this could spur an actual increase in medical treatments for minor life difficulties and serve as a rationale for extending psychotropic treatments to larger portions of the population” (2007:132). Using results from the Epidemiologic Catchment Area Study, Corrigan (2007) found low levels of participant treatment of people with schizophrenia,

and that those with more serious mental illnesses were no more likely to participate than those with less severe mental illness symptoms (Regier, Narrow, Rae, and Manderscheid 1993).

Corrigan also determined that Kessler et al. (2005) had found similar results in The Nation Comorbidity Survey (2001). It should be noted here that Kessler has long been

considered to have significant conflict of interest issues due to his longstanding relationship with major pharmaceutical companies. He has received considerable research funding from the latter on a scale that has meant by extension, he has been working for pharmaceutical companies for most of his career. Therefore, his findings should be viewed from this perspective.

As noted previously, most mental health assessment instruments fall into one of two categories, diagnostic or dimensional. The DSM series initially supported the idea the mental health is characterized by qualitative differences that can be converted to categories or diagnosis—although the DSM-III and DSM-IV and DSM-IV-TR (APA Text Revision 2000) stated specifically “that no definition of a mental disorder adequately specifies precise

boundaries between normality and abnormality” (Stein et al. 2010). In contrast the DSM-5 (APA 2013) presented a shift towards dimensional or continuous aspects of mental health. The DSM-5 also introduced a standardized method for assessing severity for all diagnoses with an emphasis on simplicity and clinical utility (121).

Several studies have been concerned with whether the public can correctly identify psychiatric disorders. These studies point to partial and often incorrect understandings. The public may recognize certain types of symptoms over others, and these symptoms may expand public conceptions of what comprises mental illness (Phelan, Link, Stueve, and Pescosolido 2000). The public’s broader definition of mental illness closely parallels another development in psychiatry: the first version of the DSM, published in 1952, contained 106 diagnoses (80), while

the fourth version DSM-IV published in 1994 contained 297 (Mayes and Horwitz 2005; Schnittker 2013:80).

For example, conduct Disorder is a DSM-IV and DSM-5 diagnosis and the criteria include “a disturbance in behavior that causes clinically significant impairment in social, academic, or occupational functioning” (2013:472). This disorder is associated with

Oppositional Disorder (ODD) in younger children and Antisocial Personality Disorder in adults (APA, DSM-5, 2013). These disorders are considered treatment-resistant or intractable and thus associated with greater stigma.

The over-diagnosis of mental illness in African Americans in childhood, adolescence, and adulthood contributes greatly to the multidimensional stigmatization of this population and further compromises life chances and outcomes. Therefore, to study individual stigma neglects the identification of the ways in which multiple stigmas and their social categories mutually construct and reinforce each other (Cole 2009).

Contextually speaking the alliance between large pharmaceuticals, the American Medical

Association, and the formulation of the DSM-III has led to the increase in prescribed

psychotropics from 13 percent of the U.S. population in 1997 to 19 percent in 2007 (Hansen et al. 2014). Prescribed antidepressants increased 400 percent between 2005 and 2008 alone (Hansen et al 2014; Pratt, Brody, and Gu 2011).