A member of the American Psychoanalytic Association posted the following on an internal email list, and I am reproducing it with permission. It captures the kind of circular reasoning behind the current paradigm of psychiatry as represented by DSM 5. As in "we define the disease by these symptoms, therefore if you have these symptoms, you have the disease."



The following two questions were published in a recent (June 8) issue of Psychiatric News and also distributed by APA in an email message, apparently as part of a PR quiz program to popularize the DSM-5. However, I'm posting them here to convey an idea of what many of us feel has gone wrong in American Psychiatry in the last decades. Each of these clinical vignettes describes a patient with some kind of mental disorder. Each vignette ends with a quiz question. Fair enough.

However, I have changed to UPPER CASE some words in the two questions to which I'd like to call your attention. Note in both cases, the question is phrased in such a way that the task is to decide which of the listed DSM-5 entities CAUSED the patient's symptoms and clinical "picture" described in the vignette. However, the real task is to try to guess which set of symptoms listed in the DSM-5 most closely matches the patient's symptoms.

Framing the questions as they are indicates a mind set that these DSM-5 "disorders" are "real" things which are somehow present in the patient (like a bacteria) and which then CAUSE the patient's symptoms. In actual fact, because there are no such entities other than in the DSM-5's attempt to classify the myriad variations of human mental disorders into convenient slots, the actual meaning of psychiatric diagnoses in the current state of our knowledge is being turned on its head in the minds of contemporary (biologically based) psychiatric thinking. As you know, in the DSM-5 all "disorders" supposedly reflect an "underlying psychobiological dysfunction" which then leads to the conclusion that all one has to do is to discern the biological mechanism underlying the disorder, find the right pill, and voila! Cured! What a great doctor! What a great specialty!! He then quotes the two quiz cases.

A 65-year-old woman reports being housebound despite feeling physically healthy. She reports falling while shopping several years ago; although she sustained no injuries, the situation was so distressing to her that she becomes extremely nervous when she has to leave her house unaccompanied. She has no children and few friends. She is very distressed by the fact that she has few opportunities to venture outside her home. Which of the following disorders BEST ACCOUNTS FOR her disability? a) specific phobia*situational subtype b) social anxiety disorder c) posttraumatic stress disorder d) agoraphobia e) adjustment disorder A 35-year-old man is in danger of losing his job; the job requires frequent long-range traveling, and for the past year he has avoided flying. Two years prior, he traveled on a particularly turbulent flight, and although he was not in any real danger, he was convinced that the pilot minimized the risk and that the plane almost crashed. He flew again one month later, and although he experienced a smooth flight, the anticipation of turbulence was so distressing that he experienced a panic attack during the flight. He has not flown since. Which of the following disorders IS THE MOST LIKELY CAUSE of his anxiety? a) agoraphobia b) acute stress disorder c) specific phobia*situational type d) social anxiety disorder e) panic disorder He references a commentary in the very same issue of Psychiatry News entitled

Psychiatry is at a crossroads, according to Patrick Bracken, M.D., Ph.D., clinical director of the West Cork Mental Health Service in Ireland, at APA’s annual meeting in San Francisco in May. “Accumulating evidence challenges the current paradigm underlying psychiatric thinking and practice,” said Bracken. The problem lies deeper than just “too many drugs....” Psychiatry is not like cardiology, he said. The mind is not simply another organ of the body, but encompasses relationships, values, and meaning. Clearly a Clearly a new paradigm is needed.

He then quotes the two quiz cases.He references a commentary in the very same issue of Psychiatry News entitled New Evidence Said to Challenge Psychiatry's Basic Paradigms that calls attention to the lost state of the discipline.