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Written by Sarah Vogel
Complementing the DSM with biology and individualized care
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To determine which abnormal behaviors constitute a mental illness, practitioners rely on the Diagnostic and Statistical Manual of Mental Disorders - the DSM. In a world that had only ever demonized or trivialized mental illness, its publication was a big step in 1952. The manual made mental illness official and real and serious businessTM. Though it wasn’t the first to try, we can thank the DSM for giving credence to injury we can’t point to - to illness that does not leave a mark on the skin.
Before the 1900s, psychology was young and diagnostics were a mess. Pretty soon, doctors were getting embarrassed every time they asked each other, “Do you concur?” and the answer was often no. Though a lot of it was way off the mark by current standards, the DSM-I provided a common language to talk about the human psyche and how to treat its dysfunctions.
But beyond its practical uses in psychiatry, the DSM is a beacon of hope for those who struggle with mental health — hope that there is a path back to “normal,” hope that with work and treatment, better days are ahead.
So it’s no surprise that they call the DSM the bible of psychiatry. This tome of diagnostic wisdom decides what is normal and what is not, what is covered by health insurance, who gets disability benefits, who qualifies for special accommodations in school, and who gets to adopt a child. It’s a big deal.
But does it deserve to be?
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The latest edition of the DSM (DSM-5) was met with a lot of flak when it was published in 2012. The biggest criticism is the same as when the first edition was published nearly sixty years ago: it is imprecise and unreliable.
In 2019, researchers at the University of Liverpool published a study concluding that the DSM is a “disingenuous categorical system”, that offers “scientifically meaningless” diagnoses. The DSM is too flexible with too much overlap, they argue. The same disorder can have different symptoms, and the same symptoms can point to different disorders.
To be fair, two disorders can exist together, it’s called co-morbidity. It makes sense that PTSD increases your chances of being depressed — PTSD makes life harder. But over 270 million different combinations of symptoms can qualify both for PTSD and depression. If there are 270 million different ways two disorders can look the same, what is the value of their labels?
In an embarrassing turn for the psychological community, even the National Institute of Mental Health (NIMH) turned its back on the new DSM. “The weakness is its lack of validity,” said director Thomas Insel. “Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.”
The concern is that such loose criteria will lead to incorrect diagnoses and false epidemics of the “worried well”. A child with a few temper tantrums? Must be Disruptive Mood Dysregulation Disorder. Mom a little too sad after Dad died? Complicated Grief Disorder. Grandpa starting to forget things from time to time? Mild Neurocognitive Disorder.
The case for stronger science is compelling. Wouldn’t it make more sense to base diagnoses solely on objective science, like neuroimaging, molecular biology, and genetics? If psychology wants to be a serious business, why not treat it that way?
Some argue that the science isn’t possible yet, but it’s getting there. We have tests for motor functions, reflexes, memory, attention, visuospatial skill, and executive functioning. We have neuroimaging that can identify lesions, atrophied gray matter, the underactivation or over activation of brain regions, and many other biomarkers that provide clues about how a brain functions.
We have a lot of tools we aren’t using fully, which is a problem itself. But it wouldn’t solve the conundrum of the DSM. Even if neurological testing were advanced enough to reliably diagnose mental illnesses, the notion of exchanging it for the DSM plays into a false dichotomy between what a person experiences and what a clinician can observe. Just because we cannot map a person’s pain does not mean that it is not real.
As for the “worried well,” are they not worried? Well, they’re obviously not too worried, because then they would be hypochondriacs, which would fall under the DSM-5’s Illness Anxiety Disorder. That label is only for the people who are excessively concerned about their health. What amount of concern is excessive? Somehow I doubt that neuroimaging is going to give us the answer to that question anytime soon.
By divorcing the individual experience from a mental health diagnosis, we throw out the baby with the bathwater. Psychology does not operate in a vacuum or a petri dish. Try as psychiatry might to be a serious business science, we will never be able to isolate variables in the same way.
I used to work with “at-risk” children. I don’t like the term “at-risk” because it doesn’t mean much, other than hitting the right notes with the auditor processing Medicaid claims. But it means they are at-risk of removal from the home for a lot of reasons — juvenile detention, violence, running away from home, self-harm, poor decision-making, truancy, and more. These kids needed serious help.
The only way to get that help is to qualify, and the only way to qualify is with one of those nice, simple, coded numbers from the good, ol’ DSM. So I don’t have a problem with diagnoses like Disruptive Mood Dysregulation Disorder, even though it’s probably not the best fit. Sure, they might have three temper tantrums a week, but what do you expect when mom has six? We can’t diagnose bad parenting, poverty, or getting dealt a bad hand — but those problems still need help.
Do we need a better diagnostic manual? There are alternatives that have been suggested, such as the Psychodynamic Diagnostic Manual (PDM), and Hierarchical Taxonomy of Psychopathology (HiTOP). Others have suggested categorizing disorders by identifying primary, secondary, and tertiary symptoms, rather than giving them equal weight.
Maybe we should ask: Why do we care so much about diagnoses at all?
We’re concerned that the “worried well” will drain the system. Why aren’t we more concerned that we don’t have a system that can manage a few hypochondriacs? People argue that the DSM will inflate diagnoses and push more people to pharmaceuticals. Is that a problem with diagnoses or with how we treat illness? The DSM isn’t scientific enough. Why aren’t we more worried that one book has a monopoly on the truth?
It may be nice to believe the world can be sorted into coded numbers and discrete categories, but it isn’t that simple. One generation’s hysteria is another generation’s anxiety is another generation’s bipolar disorder. Don’t get me wrong, the DSM can help us in many ways: using it, we can explore human behavior, communicate ideas, feel less alone, and find potential treatments for mental pain. But the DSM is not the bible, and we need to stop giving it so much power.
Even if a patient says, “Doc, I get panic attacks,” the doctor still needs to ask: “And what does that look like for you?” Having the language to discuss the complexities of human behavior does not absolve us from doing the work to understand the experience of the person sitting in front of us. When we insist so fervently that the DSM is the be-all, end-all decider of normal and not, we forget the most important part of psychology: the individual.
In my eyes, the DSM’s greatest value is the gift of hope. Hope for a better tomorrow even though the very nature of mental illness so often robs us of it. Do we need any sort of bible to accomplish that? Is the judgment of a diagnostic manual more important than compassion? Which therapist would you want: the one who wants to understand your disorder or the one who wants to understand YOU?
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