Mind the Manual

After nearly two decades since the last major revision, the American Psychiatric Association will release the controversial fifth edition of its Diagnostic and Statistical Manual of Mental Disorders on May 22. The updated version adds new conditions, such as the Internet use gaming disorder and Hoarding disorder, while it widens the criteria for existing illnesses and narrows them down for others.

Ever since reports of proposed alterations to the manual surfaced last March, clinicians have been complaining that the planned changes will unnecessarily pathologize behavior previously not considered “abnormal.” Critics further argue that the DSM represents the opinions of only a few powerful psychiatrists in that it bases diagnoses on clinical symptoms rather than objective laboratory measures. However, the psychiatric world must understand that the diagnosis of mental disorders is an inexact science. While all illnesses would ideally have identifiable biological underpinnings, the DSM-5 is reflective of current research and is a helpful tool that clinicians should continue to use in diagnosing patients. Skeptical psychiatrists need to realize that the new psychiatric manual of mental disorders is a continually changing guidebook, not a dictionary.

Mental illnesses are alarmingly prevalent in the U.S. According to the National Institute of Mental Health, about one in four adults suffers from a diagnosable mental illness every year, while half of all adults experience one during their lifetime. The statistics are worse for the college-aged: The U.S. Substance Abuse and Mental Health Services Administration reports that the rate of mental illness in young adults between ages 18 and 25 is double that of people over 50.

The greater precision of diagnoses in the DSM-5 is a step in the right direction to assigning patients proper treatment. The creation of the new disruptive mood dysregulation disorder, for example, will reduce psychiatrists’ reliance on a common bipolar disorder diagnosis. The DSM-5 furthermore eliminates the messy “five-axis” diagnostic system in favor of a new trait-specific method. Other changes include merging Asperger’s syndrome with autism and separating obsessive-compulsive disorder and post-traumatic stress disorder into their own categories rather than looping them both under the umbrella term of anxiety disorders.

Those who blast the DSM for misrepresenting psychiatric diagnosis argue that the new manual reifies disorders, meaning that it takes subjective concepts and turns them into reality. NIMH director Thomas Insel withdrew his support for the DSM in late April, citing his dissatisfaction with the DSM’s lack of a scientific groundwork. While it would be ideal to root mental disorders in biological causes, this goal is currently an unrealistic one. The 1,500 experts who contributed to the DSM-5 would have preferred to base diagnoses on genetics or neuroscience if this was possible, but current science has yet to catch up. Mental health diagnoses today are based on self-reporting, observation and behavioral interpretations.

APA president-elect Jeffrey Lieberman, M.D., reports that there are currently no objective measures of mental illness, aside from rare exceptions such as narcolepsy, which can be diagnosed by testing cerebrospinal fluid. Neuroscientists understand some of the ways in which the brain circuits for memory, emotion and attention malfunction in various mental illnesses, but this is a relatively new field and the tools to further study it are still being developed.

Many have even suggested permanently abolishing the DSM. However, the purpose of having a diagnostic manual is to allow mental health professionals to speak a common language when working with clients. Patients and families find comfort in labels, while insurance for medication, therapy and hospital care must be justified by formal diagnoses. The authors of the DSM believe that the advantages of patients receiving healthcare coverage outweigh the disadvantages of categorizing clients.

The earliest editions of the DSM were clumsy by today’s standards and lacked extensive basis in research — homosexuality was even considered a disorder in the DSM until the APA removed it in 1973. Detractors must realize that the DSM is constantly improving and smoothing out inconsistencies as science develops. 

Over the next 20 years, progressive research into the biological causes of mental illnesses will base conditions on physiological brain studies rather than categories for the sixth edition of this manual. Guidebooks like the DSM-5 will allow researchers to validly compare findings from separate studies and move closer to attaining this goal.

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