Who's Afraid of DSM? (You Should be and Here's Why)

Who’s Afraid of the DSM? (Maybe you should be and here is why)

In May of 2013 the American Psychiatric Association is supposed to release the latest version of its diagnostic manual The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). There are six previous versions (DSM-I, DSM-II, DSM-III, DSM-III-Revised, DSM-IV, and DSM-IV Text Revised). As a Clinical Counselor and Psychologist licensed in Ohio, I find the forthcoming DSM-5 troublesome for many reasons.

First, DSM-5 was supposed to link mental disorders to underlying physiological markers that would help us understand why people get these disorders. To quote psychiatrist Dennis Charney, who worked on the DSM-5 research agenda, “…the field of psychiatry has thus far failed to identify a single neurobiological phenotypic marker or gene that is useful in making a diagnosis of a major psychiatric disorder or for predicting response to psychopharmacologic treatment…current classification in psychiatry therefore resembles the medicine of 50-100 years ago, before the underlying pathophysiology of many disease processes was understood.”

Yikes! While those of us working and researching believe that severe disorders like Schizophrenia or Bipolar I Disorder do derive from problems in the brain or nervous system, we have yet to prove it. Other disorders like Major Depressive Disorder may have physical correlates but are overdetermined (meaning you could get them for many reasons).

Ok, admittedly we are in the infancy of brain science so maybe the DSM-5 agenda was too ambitious on that count. How about reliability? This means that, when used by different clinicians, the criteria in the manual consistently produce similar results (reliably measure symptoms of mental disorders). According to Allen Frances (the chair of the DSM-IV Task Force) many diagnoses in DSM-5 field trials “had crazily low reliability, far below acceptable historical standards – suggesting either that the criteria sets were poorly written or the testing poorly done – or more likely both.”

Double yikes!! So while DSM-IV had many disorders with good reliability (e.g. Major Depression) DSM-5 is going backwards? What’s the problem?

According to Dr. Frances, the problem is the American Psychiatric Association (APA) needs the money that will come from selling DSM-5. APA makes tens of millions from the sale of each edition of the manual. Every mental health professional and student of mental health disorders is a captive audience and will need to buy the manual which will likely retail well above $50 in paperback since the cost to produce DSM-5 (so far) is $25 million dollars.

In addition to Dr. Frances, Dr. Robert Spitzer, the mastermind behind the structure of the DSM categorical model (grouping symptoms into categories based on statistical analysis) has been highly critical of the secretive nature of the DSM-5 process. Spitzer was appalled when he learned that all psychiatrists involved with creating DSM-5 had to sign an agreement that they would never discuss what they were doing. Spitzer claimed this is antithetical to the public nature of the scientific enterprise.

Triple Yikes!!!

While mental disorders and the suffering they cause are real, we don’t understand what causes them, the best way to treat them, or the best way to diagnose them. As such, mis-diagnosis is a common occurrence implying that any new manual should carefully tested for reliability. Unlike all other branches of medicine, psychiatry is not dealing with diseases like strep throat; it is dealing with symptom sets that we just don’t understand. It may be that in the future will learn that Schizophrenia indeed derives from a genetic predisposition that leads to abnormalities in brain structures. Until that day the creation of diagnostic manuals should be done with care utterly lacking in the DSM-5 process. Who’s afraid of DSM? I certainly am and maybe you should be too.