Commonly referred to as "the DSM," the Diagnostic and Statistical Manual of Mental Disorders is often referred to as psychiatry's "Bible." If that's the case, imagine the outcry if an overzealous publisher merged the Gospels of Luke and Mark, and you have a pretty good idea of the controversy surrounding the release of the manual's fifth edition.
After a six-year revision process—and nearly 20 years since the last edition—the American Psychiatric Association (APA) released the DSM-5 at its annual meeting this weekend, the product of 13 working groups and input from more than 1,500 professionals. Any effort to draw a line between the normal and the abnormal is sure to ignite debate, and it's no surprise that doctors and patients who rely on official diagnoses for health-insurance coverage have scrutinized the new DSM's every word. Among the most controversial changes: Grief following a loved one's death is now classified as a form of major depression; forgetfulness in old age as "minor neurocognitive disorder"; and worrying about your medical condition as "somatic symptom disorder." Asperger's is being folded into the autism spectrum. While the new edition contains approximately the same number of mental disorders as the previous one, the 992-page manual broadens the criteria for many ailments, making it easier to obtain a diagnosis. Critics say this will classify the "worried well" as mentally ill and turn us into a Prozac Nation of dead-eyed pill poppers. The new DSM, in other words, pathologizes normal and plays into the hands of money-hungry pharmaceutical companies.
Despite cries about an oncoming Huxleyan dystopia, the more lax DSM is a good thing: Broadening of definitions of mental disorders—and yes, diagnosing more people with one—will go a long way in erasing the dirty signifiers that come part and parcel with mental illness. The uproar over the DSM-5 only shows the stock we continue to put in labels like "major depression," "OCD," and "ADHD”—and the degree to which being diagnosed with a mental disorder still carries a stigma. Would reclassifying types of skin disease cause such a stir?
Among the DSM-5's most vocal critics has been Allen Frances, professor emeritus at Duke University and the lead researcher behind the previous edition of the manual. "[The DSM-5] will start a half or dozen or more new fads which will be detrimental to the misdiagnosed individuals and costly to our society," Frances said shortly before the manual's release. “Pretty soon, everyone’s going to have a mental disorder or two or three,” he told Mother Jones.
This is a common view, but there is no proof that Americans are overdiagnosed or overmedicated. Sure, antidepressant use has skyrocketed 400 percent since 1988; an estimated 11 percent of Americans now take drugs to treat depression. It's also true that the rate of ADD has tripled in the past 15 years; 4 percent of kids now take medication for the disorder. But this doesn’t necessarily mean people are being overdiagnosed. The fact is, mental illness is far more common than most people think.
Under the guidelines of the previous DSM-IV edition, one in five of Americans would currently qualify as having a mental illness, and half would at some point in their lifetimes. While there are certainly doctors who may rush to medicate patients as a quick fix for routine anxiety or run-of-the-mill childhood misbehavior—pharmaceutical companies certainly have a financial interest in encouraging this kind of care—the primary problem with mental illness in the United States is undertreatment. Fewer than half of those who suffer from mental illness seek treatment; it’s out of reach for a great number of Americans. This is particularly the case for racial and ethnic minorities, who suffer from mental illness at rates comparable to the rest of population but are underserved by the mental-health community. For example, only one in 20 Hispanics who experience mental illness seek professional care, African Americans are 20 percent more likely than non-Hispanic whites to report serious psychological distress, and Asian-American women have the highest suicide rate of all women over 65.
Critics accuse DSM-5 of relying too heavily on self-reports from patients and the subjective assessments of psychiatrists as well. Unlike most of medicine, psychiatric diagnoses are not rooted in biology. This was essentially the criticism of the National Institute of Mental Health—one of 27 institutes and centers that make up the National Institutes of Health—which condemned the DSM-5 in a statement: "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." But as Kenneth Zucker, the chair of one of the DSM working group points out, "The data are the data. That's where the field is at." The science of the mind simply has not advanced to the point where diagnosing autism is like testing for diabetes—and given how complex and multifaceted human cognition is, it's unlikely it will ever be that straightforward.
But is that such a bad thing? While it's comforting to think the line between crazy and sane is clear—and that you're on the right side of it—the real difference between being feeling depressed and "Depression" is whether one steps into a doctor's office to get assessed and treated. It's up to the patient to decide whether his or her problem is severe enough to seek relief. This is perhaps the best way to think of the new DSM: Not as the definitive map of the human psyche, but as a flawed tool for guiding doctors to fix what ails us.
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