Is the Criticism of DSM-5 Misguided?

In 2013, the American Psychiatric Association will publish the DSM-5, the next edition of its diagnostic manual.  Public reaction has, thus far, not been favorable.  Critics decry the lowering of diagnostic thresholds in existing criteria; the conception of new diagnoses seemingly “out of thin air”; the radical overhaul of entire sections (like the personality disorders); and the secrecy under which many of the earlier planning stages were held.

Much of the criticism, including that from its most vocal critic, Allen Frances (lead author of the current edition, the DSM-IV), laments the expansion of diagnostic criteria.  They argue that this may increase the number of “mentally ill” individuals and/or pathologize “normal” behavior, and lead to the possibility that thousands—if not millions—of new patients will be exposed to medications which may cause more harm than good.

The American Psychological Association, the British Psychological Society, and the American Counseling Association have expressed their opposition publicly.  An online petition from the Society for Humanistic Psychology (part of the APA) has garnered nearly 9,000 signatures in fewer than 60 days.

I understand and sympathize with the critics, particularly against the DSM‘s emphasis on “user acceptability” over validity (and, in the interest of full disclosure, I did sign the petition).  But I wonder whether the greater outcry against the DSM-5 is somewhat misdirected. The DSM-5 may very well turn out to be a highly flawed document, but that’s all it will be: a document.  Whether it results in the “overdrugging and overdiagnosing” predicted by critics like Frances is not the primary responsibility of its authors, but of those who will use the book.  And this is where the outrage should be directed.

First of all, let’s just state the obvious:  it is impossible to write a comprehensive, scientifically valid catalog of all mental illnesses (particularly when some argue convincingly that mental illness is itself a false concept).  When we’re talking about conditions that have both biological and sociocultural origins (in fact, this has long been part of the distinction between “neurologic” and “psychiatric” disease), it seems clear that a diagnostic manual will never capture the full spectrum of psychiatric disorders.  Even if we included semi-accurate biological markers in the diagnostic criteria—a Holy Grail we’re far from attaining—mental illness will always, in the end, depend primarily upon the patient’s subjective experience.

Thus, the DSM-5, like all DSM’s before it, will be, almost by definition, incomplete or deficient.  It will be a descriptive tool, a taxonomy, a guidebook, featuring the authors’ best guess as to what might constitute a treatable condition.  For example, in real life there is no one thing called “major depressive disorder” as it appears in the DSM-IV (in fact, there are 1,497 variations).  Nonetheless, we use “MDD” to label all of our patients with these combinations of symptoms, because it’s the best fit.  But a good mental health professional doesn’t treat MDD, he or she treats the person with MDD.  Calling it “MDD” is only necessary for insurance billing, for drug companies to get FDA approval for new pharmaceuticals, and for patients and docs to give a name to (and, if necessary, demystify) their condition.

In other words, the danger lies not in the label, but in how we use it.  In fact, one might even argue that a lousy label—or a label that is so nonspecific that it applies to a broad swath of the population, including some in the “normal” part of the spectrum (wherever that may be)—may actually be beneficial, because it will be so meaningless that it will require the clinician to think more deeply about what that label is trying to convey.

As an example, consider “chronic pain,” a label frequently applied to patients and written in their charts.  (Even though it’s often written as a diagnosis, it is really a symptom.)  “Chronic pain” simply implies that the patient experiences pain.  Nothing more.  It says nothing about the origin of the pain, what exacerbates or soothes it, how long the patient has experienced it, or whether it responds to NSAIDs, opioids, acupuncture, yoga, or rest.  When a new patient complains of “chronic pain” to a good pain specialist, the doctor doesn’t just write a script; he or she performs an examination, obtains a detailed history and collateral information, and treats in a manner that relieves discomfort yet minimizes side effects (and cost) to the patient.

Perhaps this is what we can do in psychiatry, even with the reviled new DSM-5 diagnoses like “Attenuated Psychosis Syndrome” or “Disruptive Mood Dysregulation Disorder.”  Each of these new “diagnoses” suggests something about the patient and his or her behavior or experience.  But neither one should predict a course of treatment.  In fact, a vague diagnosis should actually prompt the doctor to probe more deeply into a patient’s symptoms and determine their impact on the patient’s well-being and functional status (which may actually help improve disability evaluations, too).  On a population basis, the heterogeneity of patients given a diagnosis might stimulate further research (neurobiological, psychological, epidemiologic, maybe even anthropological) to determine more specific subtypes of illness.

Will the new diagnoses be “overused”?  Probably.  Will they lead to “overdrugging” of patients—the outcome that everyone fears?  I guess that’s possible.  But if so, the spotlight should be turned on those who do the overdrugging, not on the document that simply describes the symptoms.  This may turn out to be difficult: official treatment guidelines might come out with recommendations to medicate, insurance companies may require diagnoses (or medications) in order to cover psychiatric services, and drug companies might aggressively market their products for these new indications.  And there will always be doctors who cut corners, arrive at diagnoses too quickly and are eager to use dangerous medications.  But these targets, ultimately, are where the anti-DSM-5 efforts should be placed, not on its wholesale rejection.

In the end, one could argue that the DSM-5 is unnecessary, premature, and flawed.  Unfortunately, it simply reflects our understanding of mental illness at this point in time.  But is it a “dangerous public health experiment,” as Allen Frances has warned?  Only if we allow it to override our eyes and ears, our hearts and minds, and what our patients truly need and want from us.   In the end, it’s just a book.  What really matters is how we use it.

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14 Responses to Is the Criticism of DSM-5 Misguided?

  1. Rob Lindeman says:

    Steve, I’m afraid the rest of the world, particularly the lay world, doesn’t see the DSM the same way you do. DSM labels, and labels become entities with independent existence. That, grossly over-simplified, is the problem.

    I noticed you reference Szasz on the phenomenology of mental illness. Since you use “chronic pain” as an example, you would very much enjoy Szasz’s first book “Pain and Pleasure”, published prior to his better-known second book “The Myth of Mental Illness”

  2. Jay says:

    The lack of transparency has been more than a little distressing. Yes, the workgroups have posted a number of proposed changes, but the opportunities for feedback have been sorely limited. The proposed changes to Axis II disorders are particularly confusing and may lead to even worse misapplication. Interestingly, I was recently called to court to testify in a visitation dispute and one of the attorneys was trying to present the matter as Parental Alienation Syndrome. Um, can we wait a bit and see if it is even promulgated?

      • Gayle Rockelli, MSLS, (former Medical Librarian for the APA) says:

        Why have the opportunities for feedback from the workgroups been sorely limited? Weren’t the field trials helpful in clearing up any confusion re the Axis II disorders and what about the DSM educational tools that are supposed to clear up any confusion leading to misapplication? With regard to child custody/visitation rights in court, inevitabley the Parental Alienation Syndrome pops up. As a matter of due course, attorneys are not forensic psychiatrists/psychologists and tend to pick up a DSM and ascribe legal meanings to a Diagnostic Manuel not meant to be used in that fashion in a court of law.

  3. Dr. D says:

    If I may use a bad analogy, I think it’s like you’re saying “guns don’t kill people, people kill people.” Which is completely true. But…the DSM makes it so easy to practice psychiatry by symptom checklist, and unfortunately (here’s where the analogy doesn’t apply), the DSM legitimizes this approach and makes it defensible.

    Which then leads to things like my experience at a prestigious academic medical center, where I saw patients like a young woman with clear borderline PD or an old lady going through an existential crisis get ECT just because they met criteria for MDD (and of course the meds didn’t help!).

    On the other hand, it’s hard for me to see how the DSM 5 could make things any worse than they are now, considering how many people are currently being diagnosed with _______ Disorder, NOS.

    • Gayle Rockelli, MSLS, (former Medical Librarian for the APA) says:

      I agree completely. What must the patient population think when they are at the mercy of a mental health provider who could conceivably misdiagnose them and go down a wrong path of treatment. Without evidence-based medicine and treatment outcomes, along with solid field trials, the DSM loses it’s validity and reliability as an effective diagnostic tool and, furthermore without the education, experience, skill and training of the professionals who rely on it, the DSM will remain an historical account of the changes in the diagnostic descriptions of mental illnesses, both those that have succumbed to other nomenclature, become obsolete or have become so cluttered with every description of behavior under the sun.

  4. Psychiatrists need to stop pointing fingers of blame…

    In the area of the harm caused by drugs – it’s the drug makers fault… not the person who wrote the prescription).

    In the area of providing 15-minute “med checks” – it’s managed care’s fault… never the person who runs the clinic.

    In the area of an abysmal recovery rate from the conventional approach, it’s those nasty politicians, and de-institutionalization… not the profession’s inability to develop safer and more effective options that are sane.

    And with the DSM-V…. Who’s fault will it be?
    The book’s fault.

    To the psychiatrists who read your blog…
    Stand-up.
    Take responsibility.
    And stop acting like children!

    Duane

    • lizzy says:

      couldn’t agree more.

      people are suffering like crazy. everyone plays their part. on my end, since reading more about the efficacy and risks of stimulant treatment, i feel ashamed that as a school social worker, i occasionally told parents to “see if their child’s doctor had any suggestions for their hyperactivity.” those who KNOW the dangers of these meds and the lack of empirical support for their long term use should be especially ashamed of themselves.

      is it the “book’s” fault that it might be misconstrued? no. the book is not to blame. but those who fund the book- those who wrote the book- those who use the book as a reason to over-medicate? those people? shame on them! the entire APA disgusts me!

      • mara says:

        Don’t feel too ashamed. Telling parents to check with their doctor is not bad. There are social workers who try to link not medicating a child with child abuse.

  5. Michael says:

    Article wreaks of diffusion of responsibility…

  6. Gayle Rockelli, MSLS, (former Medical Librarian for the APA) says:

    I’m all for bringing back the art and science of psychotherapeutic methods to address many mental illnesses. It’s too bad that teaching and exploring psychotherapeutic modalities are out of fashion in medical schools. The idea that a “pill” alone can ameliorate psychic pain that is part of a mental illness without using talk therapy lessens the functionality of many patients and leaves them feeling dependent on the idea that a psychotrophic medicinal approach will be a quick cure. Whatever happened to a biopsychosocial model of treatment…managed care and insurance companies or wasn’t “the decade of the brain” supposed to hold the answers.

  7. Carol Levy says:

    So many reactions to this. The invalidity of ‘labels’, for instance homosexuality once being a mental Illness, the use of DSM to drug millions of kids giving a psych name to behavior that used to be thought of as kids being kids.
    I saw my gen prac. yesterday. He asked if I wanted to get some blood work, CBC, etc, just essentially informtive and maybe preventive.
    “Medicare will not cover because it is preventative.”
    “True so we will give a diagnosis or symptoms, I’ll put down fatigue.”
    DMS the same, you want to get paid for your services you need to name why the person is seeing you. Sometimes I wonder if the drugging is (unconscious(?) way to assure insurance payment.

    (Thanks for the analogy to chronic pain.
    The ISAP (International Assoc. For Study Of Pain, among others, do consider chronic pain to be a disease unto itself. They, believe that, as some have written (I believe here) about psych disorders; that the longtime presence of chronic pain changes the brains’pain pathways.
    http://www.iasp-pain.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&ContentID=2915 )

    As for relieving discomfort and costs the analogy is a good fit. although I disagree with the ending of that sentence.
    Often pain specialists will use a buckshot effort, like with psych, and see what might stick (help).
    As for cost, even if the doc decides the dx is ‘chronic pain’, like using the DSM, he will usually (have to) pick a more specific name, in order to get paid.
    .

    • stevebMD says:

      “you want to get paid for your services you need to name why the person is seeing you. Sometimes I wonder if the drugging is … a way to assure insurance payment”

      Bingo. That’s 99% (well, okay, maybe 75%) of the problem right there, at least in the managed care/Medicaid settings where I have worked. The label begins as a “necessary evil,” but quickly becomes a defining feature of the patient, which then guides treatment more so than anything the patient says or does.

  8. [...] ago, I wrote about how critics of the DSM-5 (led by Allen Frances, editor of the DSM-IV) might be barking up the wrong tree.  I argued that many of the problems the critics predict are not the fault of the book, but rather [...]

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