I am a psychotherapist who has written a book in which I explain why the DSM-5, the latest version of psychiatry's diagnostic manual, is a mess, and how it got to be that way.

As a psychiatrist who is critical of the APA, I was wondering what your views on Anti-Psychiatry theory are. Specifically, I am a student of Dr. Jeffrey Schaler, who wrote the controversial book Addiction is a Choice, and is very influenced by Dr. Thomas Szasz. They are both very critical of the institution of psychiatry and how it socially manufactures diseases, and I was wondering if you would carry your critique that far, or are merely critical of the institution of the APA.

Thanks for the AMA, your book looks very interesting, and I'll definitely give it a read!

I agree with some of what antipsychiatrists say, and especially with Szasz. I think their point of contention is different from mine. They are more worried about issues of social control and personal responsibility than I am. I am mroe worried about issues of identity formation and the way money and related matters exert powerful influence on our self-understanding. I think the DSM is an example of those influences at work.

Sure the DSM-V has its problems, and its certainly been a tumultuous process in the making, but we are talking about an area (psychology) that is young and still in development....medicine has a stronger aura of clear diagnosis but they too are often incorrect in diagnosis or discover new explanations for things. Why should an update to a manual that is based in new research discoveries be a bad thing? What are you offerring as the alternative solution?

While you are right to state that the APA oversees development and production of the DSM, your evilization of them is a bit of a stretch to me. How do you reconcile the many good intentioned researchers, therapists, and patient-organizations, who have been heavily and importantly involved in the process?

Same way I reconcile the good people I know who work for drug companies or defense industries with the fact that their employers aren't always great citizens, and the products they make are sometimes dangerous. I note that everyone has to make a living, and in the case of the mental health biz, I include myself.

I;m not sure I evilize the APA. I am very critical of the organization, and I think for good reason, and some of their actions would be easy to explain as instances of not-good, if not evil, but overall I think I try to give the individuals their due. Everyone at APA had a chance to talk to me, and i quote them all at length an din context, giving theirbest defense of the DSM. Sometimes I had to go way out of my way to do that, because after November 2011, the organization officially cut off communicatino with me. Fortunately for me (and, I think, for them) the experts themselves remained willing to talk, and I hope I have reported faithfully on their account of what they are up to.' ' I don't think an update is a bad thing, nor is it avoidable, not in any field. But DSM updates are problematic because they expose to air conflicts and controversies frozen in amber since the last revision, which in this case was 20 long years ago, a time in which we have had any =number of diagnostic epidemics and overtreatment scandals.

Also: Can you speak to what good you feel your book does? In a profession where help-seeking behavior is low, skepticism and misunderstanding/information is high, how does your book make things better?

I suppose the answer depends on what "things" you are talking about. I doubt it will make the DSM's reputation among laypeople any better, but I;m guessing it's already pretty low. It might give some shape to people's inchoate resistance to psychiatry, which is probably part of what keeps help-seeking behavior low. It will definitely increase information, and maybe understanding, about what the DSM is, how it affects people, and why it has the problems that it does.

it's an interesting question, though. Does a book have to make things better? Can't it just describe how things and leave people to decide what to do with the knowledge gained?

You're guessing the reputation of the DSM is pretty low and reduces help-seeking behavior? Is that assumption informed by your knowledge of the help-seeking literature?

I don';t think there is much research on the relationship between esteem for the DSm and help-seeking behavior. IN fact, strangely enough, there's not a whole lot of research on how the DSM is used and to what end and with what success--or what social scientists would call clinical utility. What we do know is that in the post-DSM-III world, treatment seeking has increased markedly, four-fold by some measures, and some of this is probably due to the higher awareness of mental illness as an explanation for psychological suffering that the DSM made possible.

So I'm left with anecdotes. I've been a clinician for thirty years. I have talked, I am sure, with hundreds of colleagues. Virtually none of them thinks much of the DSM; it's a way to butter their bread. I've also talked with many non-clinicians whose sense of the DSM, gleaned from news articles or abnormal psych classes or wherever else is that it is pretty dismal. I don't think the DSM is doing much good anymore for psychiatry's reputation. I have no proof of this, but if it's true, it may well be one of the many reasons that people avoid psychiatrists, and nowhere near as important as people's fears, sometimes misplaced and sometimes not, about psychiatric drugs.

So who are the bad guys in this book? The pharmaceutical companies? The psychiatrists? The insurance providers? Are they all in cahoots?

The baddest guys are the American Psychiatric Association. The APA owns and operates the DSM. They made 110 million dollars off the last one. They also own the names of mental disorders and the criteria by which they are known. It is a unique arrangement in medicine--a private guild in charge of a public trust, in this case one that determines treatment dollars, research priorities, drug approvals, educational services, courtroom verdicts, etc. And they prove themselves to be, how should I put this?, not up to the task.

Pharma is in there too, although some might think I go too easy on them. I figure they're just doing what profit-amking corporations do, which is to sail the corporate ship on the prevailing winds. Or, to switch metaphors, the APA alley-oops them the diagnoses, and Pharma slam dunks them.

And the institution of psychiatry, which is separate frim the APA, comes in for some criticism too. It's a profession with an inferiority complex, and the DSM, at least since 1980 has been its attempt to establish its medical cred.

Is there a "better" way to identify a mental illness than the procedure for creating the DSM? I understand the process has major flaws, but do you have a recommendation for improving it?

Right now, we identify illnesses primarily through a combination of clinical signs and symptoms and biochemical findings. Psychaitry's got the first two, and probably does a better job of organizing them than othe branches of medicine. But it doesn't have the third. So the obvious solution, and they are working on it, is to identify the brain pathologies involved in mental disorder. But don't hold yourbreath. The brain's pretty complicated. And what we know so far doesn't seem to map very well onto DSM disorders.

In the meantime, two suggestions. First, that the DSM, whoever produces it, do a better job of explaining to the public what it is, which is a compendium of expert consensus about how to organize our knowledge about psychiatric suffering. It is not a collection of diseases that can be diagnosed like cancer or diabetes. Second, that psychiatry focus more on what it is really good at, for now, which is treating symptoms. Psychiatrists don't treat mental disorders, at least not in the same way that endocrinologists treat diabetes or gastroenterologists treat ulcer. That's why you have depressed people on antipsychotic drugs, anxious peopl eon antidepressants, and so on.

I would suggest that these changes would make for a much more modest psychiatry. That would be good for all of us.

Asperger's syndrome doesn't exist any more? Yeah, instant-cure!

Seriously though, what's going on with that? They've drawn a very clear line between Asperger's and Kanner's with the delay in language. Now they're directly contradicting that?

I have the suspicion that "spectrum disorders" will be the new diagnosis of the year, and be used as newspeak for "I only have a very vague idea what I'm doing, but there is definitely something I gotta diagnose. Probably." Like ADHD and bipolar before, which were grossly misused and overdiagnosed. And while it may not have much of an effect on the work of skilled therapists, the shitty ones may do more damage...

Another two points that seems completely arbitrary:

1. Ruling out Autism when there's schizophrenia, even though they're not mutually exclusive.
2. "clinically significant impairment" seems like another criterion that relies on the therapist to make an educated guess.

Personality disorders seem to be a mess as well.

"I only have a very vague idea what I'm doing, but there is definitely s=omething I gotta diagnose. Probably." It;s not quite that bad, but the stated policy of the work group that deleted Asperger's, which is not in conflict with the rest of the DSM people, is that if a patient doesn't meet the criteria, but a clinician feels they have the disorder, they should give the patient the diagnosis. That's not as crazy as it sounds. So often the point of a diagnosis is to obtain services for people in need. The problem here isn't diagnosis; it's how we distribute health care resources.

My book comes out later this week. It's called the Book of Woe because the DSM is a collection of our woes, and because it has brought hte American Psychiatric Association, its owner and publisher, many woes in the 60 years since it's been publishing DSMs. It's also b rought the APA a lot of money.

sooooo, proof?

The book is 100 proof, about the same as grain alcohol.

Read the iAMA rules.

Oh, that proof. Sorry about that. I take it a tweet will suffice, but I'm having a little trouble getting the url for my tweet linking to this discussion. I will consult my technical adviser post haste and rectify.

And here it is (or do I need to post it elsewhere?)

https://twitter.com/bookofwoe/status/329264598916145155

is it true that in America insurance companies won't provide funds for care/medication unless you have a specific code(diagnosis) from the DSM?

I remember reading something like this sometime ago but don't remember the details.

yes it is true. That is one of the biggest reasons the DSM sells as many copies as it does. But the codes themselves don't really come from the DSM. They come from teh International Classificatino of Diseases, a World health Organization document that you can get for free on the Internet.

Can you explain how the DSM works, and what the new version will mean for those of us who go to psychiatrists?

The DSM is a listing of mental disorders. Each disorder has a list of criteria. The diagnostician compares your symptoms to the list and determines if you meet the criteria. Then he or she determines whether or not your troubles are "clinically significant". (Of course, what are you doing there if they are not?) And assigns you a code, and you're off to the shrink races.

For those who go to psychiatrists, the new version will have many effects. FOr instance, if you are a hoarder, you can be diagnosed with Hoarding Disorder. If you are recently bereaved and have been badly upset for two weeks or more, you can get diagnosed with Major Depressive Disorder. If you have Asperger's syndrome, on the other hand, you will lose your diagnosis (which is not the same as being cured, mind you) and maybe become autistic instead.

How have cluster b personality disorders changed, and any comment on the pros and cons of these changes?

The personality disorders are the big mystery of DSM-5. There was an attempt to change them radically, but it caused a mutiny in the ranks. By the time it had been straightened out, the APA had pulled the draft off the web, and there were no further updates. My udnerstanding is that they went back to something very much like the DSM-IV version, but we won't know for sure until May 22.

What happened with the personality disorders is in some ways emblematic of wht happened with DSM. Experts have long agreed that sorting mental disorders into categories like major depression, anxiety disorder, etc. , is not such a great idea because mental disorder exists on a spectrum. This is especially true in personality disorder; it is impossible to say where a personality trips over the line from eccentric or difficult to sick. So the committee in charge of the PDs took it upon themselves to create the dimensions that could place people along the spectrum. But between the lack of good science, the haste with which it was done, and the fact that many careers would disappear if narcissistic personality disappeared from the DSM, whcih was one of the proposed changes, the attempt met with stiff and bitter resistance. Even some proponents of changing the approach came out aginast the draft. The result: chaos, friction, and a section probably no better than what came before.

I'm a layman - heck, not even a layman, I'm a patient. Is this book for me, or is it something academics discuss over brandy?

Oh, no. Not academic in the least. A rollicking good tale of corporate malfeasance and professional complicity, in whicxh you will learn why you got the diagnosis you got and how little it really means.

How could the DSM be successful for 60 years despite being that bad?

Because it is the only game in town. No one else wants to do it. Would you?

Do therapists actually use the DSM in practice to guide them in treating patients? If not, then how can they assess whether something is actually wrong with the patient and whether they can help them?

The DSm is not a treatment manual, but some therapies claim to be targeted to its diagnoses. Cognitive behavioral therapy in particular claims to be useful to treat Obsessive-Compulsive Disorder, Major Depressive Disorder, and Generalized Anxiety Disorder with the same kind of specificity as psychiatric drugs. So for therapists practicing CBT by the book, the diagnoses are key. But for most therapists, it is merely a means to the end of insurance payments and has nothing to do with treatment. And that;s not just hte way I see it. In my book, I interview a past president of the APA who, when I ask him to tellme the value of the DSM in a case he described to me, says, "I got paid."

What was the underlying reason for the removal of Aspergers as a diagnosis?

The official reason is that Asperger's is not different enough from autism to warrant its own diagnosis. The way psytchiatrists say this is that people with Asperger's are on the autism spectrum. The unofficial reason is that Asperger's had gotten out of hand. It was being used by too many clincians to give a label to too many people who were just odd or awkward. That had some bad effects: increased costs for special services. It also made the DSM look bad, if all of a sudden all these people had a disorder that didn't exist in 1994. So they had to find a way to rein it in.

Can you talk more about the diagnosis for Major Depressive Disorder for recently bereaved people? Why would they change that diagnosis (and what was it before)?

People who are recently bereaved often meet the criteria for the depression diagnosis. This is an obvious problem--do we really want to say that grieving people are mentally ill? In recognition of this, when the criterion-based diagnostic scheme came into existence in 1980, they carved out an exception, modifying it in sub sequent editions, so that by 1994, with DSM-IV, you had to have those symptoms for more than 2 months before warranted a diagnosis. As of May 22, the bereavement exclusion disappears, so once you've had symptoms for more than two weeks (the threshold for depression), you can get the diagnosis.

Why did they change this? The official reason is that people were slipping through the cracks, that the bereaved really did have depression, and were not being helped because docs weren't diagnosing them. In real life, I don't think this bears much scrutiny, because there is nothing legal to stop any doc from prescribing any drug regardless of diagnosis. 72 percent of antidepressants are prescribed without a psychiatric diagnosis. So nothing to stop the bereaved from getting treatment.

I think the real reason is that the bereavement exclsuion was an embarrassment. In part, because some researcher4s showed that there was no reason to exclude bereavement and not other terrible things, like unermployment, divorce or foreclosure. The choice was to add a bunmch of exclusions or to dispense with it compltely. The former was unacceptable, since the whole premise of the DSM is that mental illness is mental illness--does it matter what caused your diabetes or lung cancer? So they went with consistency, at the expense of common sense.

From a layman's perspective, two things about DSM jump out:

1) Many of the various "disorders" seem like renderings of conventional personality types, operating in characteristic and predictable, although unhealthy, ways; that is, they seem like they are actually the negative poles of different spectra, instead of the out-of-nowhere, random boxes DSM assigns. Examples:

Impulsive Partier-->Hysteric

Glory-Craving Achiever-->Narcissist-->Sociopath

If this is the case, wouldn't it be more effective to focus on what's healthy for a given type, and then edge a given patient back along his or her characteristic spectrum, instead of boxing someone as (near-insolubly) Neurotic vs. (very generically) Normal, then issuing pills to try make up the difference?

2) Those disorders that don't seem to be exacerbated variants of standard personality types often seem to be clumsy and random-- things like Keeps Taping Soy Sauce Packets to Coffee Mugs Disorder, to use an only slightly exaggerated example. This is another way of saying that these sorts of "disorders" seem superficial; they seem to take symptoms "at their word" rather than uncovering structure. Is there a reason that more firmly-directed symptom-management approaches, like CBT, or more penetrating analytic approaches, like NLP, are not used more often?

1) That's sort of what they tried with the personality disorders. There are reasons to think this approach can work, but it's going to take a long time to establish the dimensions and the instruments that will measure them. AS to focusing on what is healthy, I think there's a move among personality theorists to do that, but the DSM is by its nature about pathology. So in that context, what you suggest wouldn't work. However, your larger point, the one about making up the difference with drugs, is well taken.

2)The DSM by design takes symptoms (and signs) at their word. The innovation of the DSM-III, which came out in 1980 and radically differed from prevous editions, was to divorce considerations of psychopathological symptoms from considerations of the nature and causes of psychopathology. Some people call this superficial. Some call it phenomenology. Eitehr way, the reason to avoid explanations is to prevent psychiatrists from coming up with an idea like the one by which homosexuality was considered a disease--becasue, Freud supposedly argued, it was the result of an intrapsychic conflict. Of course, removing those considerations also makes it impossible to say with certainty what makes a given behavior, mood, etc., a mental disorder.

Thank you for this. As a recently diagnosed (only a month ago) this stuff confuses me.

So, in DSM-V Aspergers falls under ASD. What does that mean for the people who have adjusted so that they only need minor help now?

And now Im curious, how is it a mess?

No one knows what the change in autism diagnoses will mean. Some peop0le think it will exclude those who would otherwise get a diagnosis from receiving it, others believe it will make little difference. One thing is for sure: you aren't the only one who will be confused. I write extensively about the Asperger's debate in my book. Perhaps it will u nconfuse you. Or not.

so what exactly is your problem with the dsm-5? just the corporate aspect?

My problem with DSM-5 in particular is that it was poorly planned and executed, especially in the field trials, the tests designed to check out the changes. I know this firsthand because I was one of the field trial clinicians, and I saw teh disarray and poor methodology of the studies up close and personal.

My bigger problem is with the DSM in general, which, even in the opinion of the people who support it, is at best a sometimes useful guide to psychiatric diagnosis.My critique of DSM in the book is mostly not in my words. it comes directly from the mouths odf the psychiatrists who make it. They hoped to solve some of its problems ibn DSM-5, but they were not able to, and I think this may well be becasue the project is misbegotten. For now anyway, our psyches simply can't be parsed in this way.

I am not sure why narcissism was removed, it seems like a valid personality disorder? At any rate, may I ask for the name of the book, I am curious.

Narcissistic Personality Disorder was not removed. The original personality disorders proposal slated it for removal, but teh people who research and treat it raised a huge fuss and the proposal was rescinded. So you can still be an official narcissist.

What made you decide to become a psychotherapist?

How much do you charge per hour?

How much do you earn?

:)

Being a therapist was about the only way I could figure to make a living by telling the truth. I charge anywhere from 50 to 140 dollars an hour, depending on how much money a client has. I work about 18 hours a week. You can do the math.

I should add that writing is also an opportunity to tell the truth. But harder to make a living at.

I don't have a question, I'd just like to say that it's nice to know that someone with more credibility than me expresses some of the same concerns about the DSM. As a patient I've had to deal with some of these problems first hand, and as I've read into it I've noticed even more potential problems. It has led me to become fed up with the field of psychiatry, as I often felt like I was being treated more as a list of diagnoses (or misdiagnoses, as the case was for a period of time) than as an unique individual. I will definitely be checking out your book.

Thanks. And thanks for taking the time to say that.

How should the DSM include FASD, Fetal Alcohol Spectrum Disorders, the mental (not physical) effects of being prenatally exposed to alcohol? FASD is not in the current DSM, is very under-diagnosed, and people with FASD often get diagnosed with Autism or ADHD instead in order to qualify for services. Thanks!

Good question. I don't know the answer. I'm sure the neurodevelopmental work group took up this question, but no idea what or why they decided.

What kind of research went into this book? How did you get access to some of the information in the new DSM, and what kinds of interviews did you conduct?

I was embedded with the troops int he DSM wars for about eighteen months. I went to meetings, interviewed people of all ideological stripes in person and on the phone, read up on the history of the DSM and psychiatric diagnosis in general. (Some of this research I'd already done for my previous book,Manufacturing Depresssion.) I talked to all the principals--the people in charge of the APA., the people in charge of the DSM, many of the people on the committees that wrote it, and the opponents. The DSM-5 drafts were published on the Internet and available to the public until last June. I do not know exactly what will be in it, although the instances I've cited here are about 99 percent certain.

What are your views on Dimethyltryptamine, and its possible therapeutic effects that can be associated with them?

DMT, not to be confused with DSM, is a naturally occurring tryptamine, the psychoactive ingredient in, among other plants, ayahuasca and possibly the only psychedelic drug found in the human body. It's been used widely for psychotherapeutic purposes ranging from addiction treatment to the treatment of personality disorders. For people who are interested in that kind of experience, there is a wealth of information about it at www.erowid.org

When will your book come out in paperback for us poor people? I really enjoy your mental health reporting. Thanks for doing this AMA!

It will come out in paper, but probably not for a year or so. Find me on my website, plead your case, and, like a drug company, I may be able to give you a reduced price.

Why no social workers on the board? We do just as much clinical Therapy. And it seems we're wanted over LCPs these days.

On which board? There were social workers among the DSM-5 panelists, i believe. Go to dsm-5.org. The "who we are" link was still alive last I checked. You can see for yourself if there were social workers on it. But no doubt underrepresented. Psychiatry is the smallest of the mental helath professions, but by far the largest contingent on the DSM-5 panels.

Graduate Counseling student here with a question. You may have addressed it earlier but I didn't read through everything. Anyways, what's your take on how alcohol/drug abuse and dependence were merged into a single diagnostic label with various specifiers for the actual substance(s) used? I've read that there are some practical purposes for this merging that I'm sure you're aware of. Any thoughts on this subject?

The stated reason for the rearrangement was to get out of the business of distinguishing between "abuse" and "dependence," and to go for a "supercategory" encompassing any kind of problematic drug use. It's not a bad idea, but the diagnostic threshold was lowered, and this may mean an increase in prevalence. But no one knows yet, partly becasue the new DSM hasn't gone into effect and partly because the APA did not study prevalence very hard in its field trials. And the prevalence issue is very knotty. See my article on this subject at http://www.newyorker.com/online/blogs/elements/2013/04/the-dsm-and-the-nature-of-disease.html

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That would be fun. Then someone else could write a book about taht book. maybe evcentually it would circle back to me writing a book about the other books.

And how does that make you feel...?

Like a million bucks.

So when you state that the DSM-IV is not a treatment manual, does that mean one cannot self-diagnose according to its guidelines for a particular disorder?

According to the APA, the manual is for use by trained clinicians only. The reason for this, they say, is that only a clinician can assess clinical significance, i.e., whether or not the symptoms really add up to a mental disorder. But of course the manual lends itself to self-diagnosis quite easily, and people do it all the time.

Thanks for your AMA. Can you expand on how changes to the DSM impacts patients? I have been diagnosed with major depression and PTSD. How would a change in the definitions of those disorders impact my treatment?

Can you talk about the flow of treatment? I see a psychotherapist who has diagnosed me and I see a psychiatrist who helps me with medication. My psychotherapist is not also a psychiatrist and cannot write prescriptions -- does that impact the "meaning" of my diagnosis from her?

The names for my problems don't really matter to me but I am interested in how changes impact me and others.

The DSm is not a treatment manual. Theoretically, changes in diagnoses or diagnostic criteria will not affect treatment. Those two disorders will remain relatively unchanged in DSM-5. What can be affexcted by diagnoses is the extent to which treatment is paid for by insurers.

I would bet that your therapist takes the diagnosis in an entirely differen t way from your psychiatrist. I strongly suggest you ask both of them what the diagnoses mean to them.

How long did it take you to write it?

A year or so,not counting when I was too lazy to write.

Is there any chance they can undo they can split autism back so it's not all under one name? (that's what I've gathered from this whole debate over it.) also is Internet addiction going to be listed in there or is that still questionable

Internet addiction is not going to be in the DSM-5, at least all indications are that it won't be.

I doubt you'll see autism split up again, ever. The DSM is moving toward spectrum disorders, and autism is among the first.

it's my understanding that the sudden rise in autism diagnoses came about from the publishing of the DSM-IV and the relaxation of the criteria for a diagnosis. Are there any equivalent, "goddamnit, cue a bunch of stupid people thinking there's an epidemic" kind of changes in the DSM-5?

See my response above. I would add that part of the reason to remove Asperger's was that the patients were taking it over. People were self-diagnosing, and this is a threat to psychiatry.

As for changes that will repeat this problem, my vote is for Somatic Symptoms Disorder, which you will be eligible for if you 1) are sick and 2) are really worried about it.

I was surprised to read that they're removing the bereavement criteria for Major Depressive Disorder, but when I find things like this: http://www.dsm5.org/Documents/Mood%20Disorders%20Work%20Group/Bereavement%20Exclusion%20Debate%20-%20W.Coryell.pdf, they seem to back up their decisions with research and findings.

Similarly, the removal of Asperger's syndrome seems to be backed up by what others have posted in this thread based on research.

I assume that this is the case for all their changes (research-based changes), so I'm just curious whether your disputes are actually just your own personal disagreements and you're just pandering to people who are uneducated on the matter. I can't seem to fault their changes.

Does your book go into any depth on research suggesting the opposite of these findings, and can it accurately dispute the research suggesting these changes? For example, how do you explain the Asperger's removal and the removal of the bereavement clause when the information seems to suggest this change is logical?

I think I give the research its fair shake in the book. I don't think this is the right forum for the specifics, but you can find the skinny on bereavement, at my blog http://www.garygreenbergonline.com/w/?p=262 This will link to other critiques of the research.

For Asperger's, bear in mind that the research can't prove that Asperger's is or is not a separate disorder. That's the kind of decision that gets made and then implemented if it proves useful and not harmful. Whether or not this is the case remains to be seen. Early indications are not promising, but anything can happen.

My understanding is that the axis system is being done away with to put all disorders on a more even playing field. I heard that this is being done in an effort to have more things covered by insurance companies.

However, do you believe insurance companies are going to be using the "intensity" rating (the exact wording of which I forget) as a measurement of what warrants coverage by insurance?

How do you believe this new edition will change the relationship between mental healthcare professionals and insurance companies?

The mulitaxial system is being removed. Part of the reason is that treatment of Axis 2 disorders, mostly personality disorders are generally not paid for by insurers. But the biggest reason is that the axes just don't make much sense, scientifically or bureaucratically.

I don't know what will become of the Global Assessment of Functioning rating scale that is part of a DSM-IV diagnosis. It is true that some insurers used that scale to determine treatment reimbursement, but clinicians learned how to game that system pretty fast.

As for the overall effect of the DSM-5 on the relationship between mental healthcare provieders and insurers, I hope it makes us clinicians rethink our relationship with insurers, and with the medical industrial complex. In so many cases, our involvement with insurers is not in good faith. We hold our noses and jot down a code so we can get reimb ursed. This seems strange to me--placing a lie at the foundation of a relationship supposedly based on truth. I think we'd be better off if we just made less money and conducted our business more honestly.

How do antidepressants work? Do they work on people who are depressed because of a chronic medical condition?

I'm sure there is research on the efficacy of antidepressants on people whose depression is related to another medical condition. But I don't know what it says.

AS for how they work, the short answer is that they generally affect the metabolism of neurotransmitters in a way that causes them to stimulate brain receptors more than they otherwise would. But beyond that no one really knows just how they work. The smart money is on the likelihood that changing the neurotransmitter metabolism has some kind of downstream effect (for instance, causing more growth of new neurons) that we haven't quite discovered yet.

I've ever heard any controversies with the DSM, and I am in school for psychology (forensic psychology). Why exactly is it a mess?

Some of the mess is about specific controversies. For instance, the DSM-5 will no longer carve out an exception from the Major Depressive Disorder diagnosis for recently bereaved people. So if you're upset about the loss of a loved one, and your upset lasts longer than 2 weeks, you can get a diagnosis of a serious mental illness that will stay on your medical record for the rest of your life. Asperger's disorder will be deleted frm teh manual, which means kids getting services in school might lose eligibility. It will be easier to get a diagnosis of ADHD, which is a good thing or a bad thing, depending on what you want.

So those are the controversies. Why is it a mess? Because the DSM represents an attempt to pour the old wine of human psychospiritual suffering into the new skin of scientific medicine, and it doesn't quite work. And to the extent that it doesn't work, it threatens some important and entrenched professional and politicla interests.

Have you or anyone you've know think that ADHD and autism belong on the same spectrum? Asbergers and ADHD in particular I've always found quite similar on a surface lvl

The technical answer to this question is that ADHD and autism, especially high functioning autism (including Asperger's) share many symptoms. And there are some people who think they should be lumped together. Psychiatric diagnosis is always treading the line between lumping and splitting. In the case of Asperger's, the splitters won in 1994, when the disorder was created, and lost in 2013, when it was lumped in with autism.

There have been five versions or editions of the DSM. My understanding is that it attempts to diagnose or define every human behavior and certain definitions and conditions have been added and removed over the past 60 years. Have humans always been quirky and are we getting quirkier?

I surely hope so. Otherwise, we're wasting our time.

The DSM didn't try to be a psychpathology of everyday life until 1980, which is when psychiatry, after a series of embarrassing events, found itself in a credibility crisis. Its solution was to jettison the psychoanalytic concepts it had been based on for sixty years or so, but it had to reassure its members, who were watching their bread-and-butter diagnoses like anxiety neurosis disappear, that they would still be able to get insurance payments. So they more than doubled the number of diagnoses, eventually covering everything from bad handwriting to bad hygiene.

What's your opinion on the chemical imbalance theory. On some things like OCD ADHD an depression? Asking since it drives me nuts to see people online scaring people looking for help and moving people away from the idea of medication.

There are many reasons to take psychiatric medications, not the least of which is that they work for some people. But among them is not the fact that they correct "chemical imbalances" in the brain. That was a theory some years ago, and it is a very appealing theory since it makes the whole thing sound reasonable and rational, but in fact no one knows what the relationship is between the metabolism of neurotransmitters (like dopamine or serotonin) and behavior, nor does anyone understand (yet) why increasing or decreasing activity of those chemicals in the brain changes mood or thought or behavior. So my opinion of the theory is that it is a myth. But that doesn't mean people shouldn't take the drugs, or that they can't benefit from them. Just because we don't understand them, that doesn't mean we shouldn't use them. It just means we should be cautious.

A Psychotherapist? Not a qualified Psychologist? Right - got you. You have lots of opinions. How exciting for you. You published them. How boring for us. Get some clues and do some heavy editing.

Not sure how my credentials enter into this, but, as they say on the web, FWIW: I have a Ph.D. in clinical psychology. I am licensed in my state to practice as a Professional Counselor. I was eligible for licensure as a psychologist (probably still am), but never saw the point. I have been in practice for thirty years. I have written four books on the general topic of psychiatry, numerous articles in magazines like Harper's and the New Yorker, won a couple of awards, etc., etc. And yes I have a lot of opinions.