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New DSM (psychiatry's 'bible') may be out of date before it's published

dsm 4 photo
The Diagnostic and Statistical Manual of Mental Disorders is set to be updated with a new edition next month, but controversies over the classification of mental disorders still rage.

Next month brings the long-awaited publication of the updated (fifth) edition of the “Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the symptom “bible” for psychiatrists around the world.

Debate about the revision, which got under way in 2007, has been ongoing and won’t end with next month’s publication. Much has been written about the controversies, particularly about the expected tightening of the criteria for autism and the adding of bereavement as a symptom of major depression.

But, as Nature reporter David Adam points out in a recent article, there’s been a bigger and broader debate overshadowing the revision, one that has received less media attention but that gets to the very essence of how psychiatrists — and the rest of us — think about mental illnesses:

The stark fact is that no one has yet agreed on how best to define and diagnose mental illnesses. DSM-5, like the two preceding editions, will place disorders in discrete categories such as major-depressive disorder, bipolar disorder, schizophrenia and obsessive-compulsive disorder (OCD). These categories, which have guided psychiatry since the early 1980s, are based largely on decades-old theory and subjective symptoms.

The problem is that biologists have been unable to find any genetic or neuroscientific evidence to support the breakdown of complex mental disorders into separate categories. Many psychiatrists, meanwhile, already think outside the category boxes, because they see so many patients whose symptoms do not fit neatly into them. [Dr. David] Kupfer, [a psychiatrist at the University of Pittsburgh and head of the task force overseeing the DSM-5 revision], and others wanted the latest DSM to move away from the category approach and towards one called 'dimensionality,' in which mental illnesses overlap. According to this view, the disorders are the product of shared risk factors that lead to abnormalities in intersecting drives such as motivation and reward anticipation, which can be measured (hence 'dimension') and used to place people on one of several spectra. But the attempt to introduce this approach foundered, as other psychiatrists and psychologists protested that it was premature.

Thus, the new DSM will continue to silo mental illnesses, says Adam, even as the walls of those silos are being broken down in clinical practice:

As psychiatrists well know, most patients turn up with a mix of symptoms and so are frequently diagnosed with several disorders, or co-morbidities. About one-fifth of people who fulfill criteria for one DSM-IV disorder meet the criteria for at least two more.

These are patients “who have not read the textbook,” says [Dr.] Steve Hyman, who directs the Stanley Center for Psychiatric Research, part of the Broad Institute in Cambridge, Massachusetts. As their symptoms wax and wane over time, they receive different diagnoses, which can be upsetting and give false hope. “The problem is that the DSM has been launched into under-researched waters, and this has been accepted in an unquestioning way,” he says.

Unfortunately, “the ingrained category approach is actually inhibiting scientific research that could refine diagnoses,” notes Adam, “in part because funding agencies have often favored studies that fit the standard diagnostic groups.”

But other factors also encourage the status quo, he adds:

The proposal [to introduce dimensionality to the DSM-5] was also unpopular with patient groups and charities, many of which have fought long and hard to make various distinct mental-health disorders into visible brands. They did not want to see schizophrenia or bipolar disorder labeled as something different. Speaking privately, some psychologists also mutter about the influence of drug companies an their relationship with psychiatrists. Both stand to profit from the existing DSM categories because health-insurance schemes in the United States pay for treatments based on them. They have little incentive to see categories dissolve.

You can read Adam’s article on the Nature website.

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Comments (12)

Procurstean

We behaviorists have known this for years!
The DSM's weakness has always been that it describes symptoms (behavior patterns) out of context. Since similar effects can have different causes, it lumps together problems due to different circumstances that call for different solutions.
There's no substitute for treating each individual as an individual, and looking for the specific cause for a specific problem, and them outlining a suitable treatment program.
Given this, the DSM's limited reliability in producing diagnoses is not surprising.
And you're sources are right; the DSM exists mainly to provide insurance reimbursement categories.
That's at least partly why the diagnosis of autism syndrome disorders has increased: reimbursement for their treatment has become readily available.

The REAL Rub in the DSM

and most of the psychological and mental therapy field today,...

is that it lacks any concept of the deeper, unconscious functioning of the human psyche.

Freud realized there was something there, but never adequately understood what it was because he was too busy projecting his own dysfunctions onto all his patients. (Having developed the ability to be a hammer to his own particular set of dysfunctions, he saw everyone else's problems as nails needing a similar external or internal hammer.)

Our therapists treat only symptoms with the equivalent of kiss it and make it better caring and listening,..

or offering pain killers to those who are in pain,...

whether than pain is from a broken heart or a broken mind.

Yes, there are chemical imbalances and brain wiring issues that cause SOME identifiable conditions, schizophrenia and autism, for instance,...

but there is an underlying mechanism in the brain that's still reacting to the world around us,...

and programming us to try to avoid situations which have caused us what seemed to be life-threatening emotional or physical pain,...

a mechanism which is now so far removed from it's original purpose and function that it often misfires and causes us a wide variety of personality dysfunctions.

I can't understand WHY our therapists and scientists have not and do not ask the question: What is the psyche trying to do when it programs a person to exhibit "borderline personality disorder" (for instance) in response to the events they've experienced?

There's a deep logic and reason behind our dysfunctions. The psyche is trying to protect us from future life-threatening pain (and trotting out the earlier versions of ourselves because of their seeming survival skills, when we can't avoid pain).

Can we PLEASE start figuring out what the psyches of people with personality disorders are up to and figure out how to deprogram the deep, unconscious subroutines that the psyche has created in order to do so - subroutines that generally create problems far MORE than they provide protection?

As far as I'm concerned, the DSM's categories are useless, without such and understanding of the deeper functioning of the psyche and will be radically changed when such understanding is finally developed.

Greg

I think that you're reifying an inferred hypothetical construct.
Another term that you might look up is 'homunculus'.

This sort of dualism has a long history; see
McCorquodale, K. & Meehl, PE (1948). On a distinction between
hypothetical constructs and intervening variables. Psychological Review, 55, 95-107.

All of Which is a Very High Class Way

of not responding to the issues I raised.

Pseudo issue

There's only an issue to address if the entity 'Psyche' exists.
At least from a scientific viewpoint, any entity must have a real location in time and space.
You are taking a dualistic approach which says that some entity labeled the Psyche exists separate from the brain and behavioral functions which you claim that it is needed to explain. If there is a Psyche, therefore, you must support its existence as a real entity rather than simply as a concept label (see Gilbert Ryle on the reification of category labels).
So far you have not done that; you have just posited that such an entity exists and that it can account for phenomena that other entities can't.
So no, I can't respond to the issue that behavioral and neural scientists are neglecting an important variable until I have a reason to accept that variable's existence.

Survey on attitudes towards DSM-5

There has been extended conversation and controversy around the development of DSM-5. My colleagues and I at Massachusetts General Hospital recently conducted a survey on clinician perceptions and concerns about DSM-5. Many clinicians do indeed have concerns about translating the revised guidelines of DSM-5 into clinical practice. For anyone who is interested, the free, full survey results are available here: www.mghcme.org/dsm5

It doesn't really matter

Everyone treats symptoms anyways regardless of diagnosis. DSM is really just a vehicle for payment in the end. You can't bill for anything without a DSM code. In reality for instance anyone who's actually treating a patient for depression knows if grief is a factor, and they treat accordingly. All these new versions just move the deck chairs around with little if any practical effect.

Once and while things goe seriously off the rails with diagnosis such as "Dissociation" that created a multiple personality epidemic back in the 80s and 90s but by and large it's a hollow splash.

There no reason to suppose a "spectrum" approach would solve any problem because experience with "spectrum" disorders such as Autism hasn't really demonstrated improvement, it just tends to expand criteria and make it murkier. We create increased diagnosis but show little improvement because we don't have resources to meet the increased demand. Look at the article in the Sunday Strib about the restraints in the schools: http://www.startribune.com/local/205024611.html

The problem isn't the DSM, the problem is our lack of any rational medical treatment system. The only reason we run into problems is everyone is fighting for limited treatment and research dollars. It's not that we don't dump a lot of money into the system, it just doesn't get spent on actual treatment.

And part of THAT problem

is that in many (maybe most) cases the problem is not a medical one; it is not caused by some form of organic malfunction. Rather, it is a result of the way people interact with their environmental situations; particularly social ones. In other words, a learning problem.
The brain is the immediate cause (mechanism) of behavior, but we need to identify the more remote antecedent causes (experiences) which actually determine behavior. Just studying the brain is like taking apart a computer transistor by transistor and trying to predict its output. You need to understand the software -- how it was programmed.

Certainly there are genetic predispositions, and some medical problems which have behavioral effects, but these are the minority.
The DSM is an example of the medicalization of a problem, which is at heart a trade guild issue -- who will get paid for the treatment.

Greg's question

A tad off topic but:

"Can we PLEASE start figuring out what the psyches of people with personality disorders are up to and figure out how to deprogram the deep, unconscious subroutines that the psyche has created in order to do so - subroutines that generally create problems far MORE than they provide protection?"

Actually Greg, the reason we no longer ask that question is it was a dead end that produced very little beyond structured conversation for the worried well. Notions of independent psyches, or subconscious, or "programming" were developed and explored for decades without yielding anything but subjective interpretations and psychiatric fads masquerading as treatment.

To be sure, different people have different levels of personal insight, but human behavior by and large isn't that mysterious. Personality disorders are actually quite transparent. The borderline personality you mention has pathological inability to develop adult relationships driven by a deep seated drive to recover and preserve childhood. All you have to do is ask: "how is this behavior or attitude preserving or reclaiming this persons status as a child?" The problem with describing this as some kind of psychic objective is it puts the thoughts and behavior outside the persons control which ultimately sabotages treatment, you end up with a professional patient.

The problem with computer analogies is they assume some kind of programming language that's never been discovered and create an abstracted black hole. One thing cognitive science has proven is that brains don't work like computers and that animal learning and memory does not rely on hard drives or any other similar device.

Real psychiatry isn't like the movies.

Different ways of seeing the same symptoms

I am of the understanding the borderline personality disorder results from attachment problems and the inability to regulate emotions. These have origins in childhood environments but probably require a genetic vulnerability as well, sort of the stress dyathesis model. Though obsessions over causality and etiology are the stuff that makes for professional patients. DBT simply works with behavioral management through contingencies and is the only method with any evidence for BPD.

Actually Borderline Personality has a huge cultural factor

Here's the thing about Borderline Personality disorders, they are a predominantly American phenomena that occurs mostly amongst young white middle class females. Thus far no common familial factors have been identified much less genetic factors. In fact they are remarkable in that they appear to emerge from unremarkable family backgrounds. Their families don't seem to be any more dysfunctional than anyone elses.

Now for while there everyone thought they were coming from abusive families, and eventually for a while in the 90s borderlines were converting into multiple personalities with histories of satanic ritual abuse. But that all turned out be bogus.

This points to a cultural etiology rather than a medical cause. One thing that borderlines teach us is that serious pathology is not necessarily produced by seriously dysfunctional families or parents.

Speaking privately...

"Speaking privately, some psychologists also mutter about the influence of drug companies..." My. Such an odd, cowering way of describing a vocal, organized, institutionalized, well articulated and international campaign on the part of psychiatrists, physicians, journalists, researchers and advocates to stem the takeover of medicine by industry.

I think dimensionality is well enough if it leads to the further erosion of our cultural constructs about mental illness. These diagnostic categories have already done far too much damage, and if you doubt that, have a look at Anatomy of an Epidemic by the journalist Robert Whitaker. I'm beginning to think Foucault and RD Laing and Erickson were right all along, that the role of society in vulnerable individuals is the driver of symptoms that we have arbitrarily categorized according to how they impact the ability to function in our society at this time. Whatever the solution, the medications now in use clearly are worsening disability rates and making mental illnesses that were once transitory chronic. I'm afraid the biobabble corner that psychiatry has chosen is an error that will take decades to reverse.