Is the Criticism of DSM-5 Misguided?

December 15, 2011

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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