“This is a corner piece of the jigsaw puzzle.” An international study published in the…
Controversy Surrounds New DSM 5, Culmination of 61 Years of Psychiatric Study
On May 22, 2013, the American Psychiatric Association released the fifth edition of its highly influential Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This manual identifies and classifies mental diseases and conditions of all types, using the catch-all phrase “disorders” to describe afflictions that are believed to have both psychological and biological/neurological characteristics. The DSM is used by psychiatrists, psychologists and other medical practitioners to diagnose specific mental conditions in patients who are experiencing problematic psychological symptoms, and the manual also contains valuable information about the latest research and clinical findings that can help medical professionals prescribe comprehensive and effective treatment for any disorder they may encounter.
From humble beginnings, the DSM has now become such a standard text in the field that it is sometimes referred to as the Bible of the mental health profession.
Toward an Inductive Science of the Mind
The DSM was able to reach such an exalted status because it filled a void that had existed since the 19th century, when the first attempts were made to bring scientific methodology to the study of mental illness. Because the early orientation in the profession focused on the collection of intricate statistical data, mental health researchers have traditionally steered away from ideological or theoretical explanations for illness and have instead sought to establish clear-cut diagnostic categories for the purposes of organization and clarity. Individual practitioners are left free to interpret disorders however they please, but the DSM has made their task much easier by providing them with a symptom-based framework of classification that eliminates guesswork and uncertainty from the equation.
Deductive scientific reasoning starts with a theory and then interprets data and draws conclusions about meaning while working within that pre-chosen context. Inductive reasoning, on the other hand, collects facts in massive quantities and then attempts to organize them into more general categories based on connections and relationships that emerge organically. From the beginning, the framers of the DSM have attempted to rely largely on an inductive approach that moves from the study of symptoms to the identification of specific illnesses that can be grouped within broader classifications.
Mental Illness Emerges into the Light
The first Diagnostic and Statistical Manual of Mental Disorders was released by the American Psychiatric Association Committee on Nomenclature and Statistics in 1952. This 130-page manual was partly inspired by the work of the US Army and the US Veterans Administration, which in the years immediately after the end of World War II carried out innovative studies of mental illness and neurosis in veterans who had returned to civilian life after experiencing combat. During this same period of time, the World Health Organization (WHO) published a groundbreaking 6th edition of their widely read and analyzed International Classification of Diseases, which made history by becoming the first publication to include mental health disorders among its comprehensive listing of all known human diseases. The first DSM was issued just three years after the WHO added this stamp of legitimacy to the concept of mental illness, as APA officials decided the time was right to release an authoritative manual that would focus on the specific symptoms associated with discreet psychiatric disorders, thus making it easier for clinicians to make accurate diagnoses in patients suffering from psychological maladies and maladjustments.
Between 1952 and 2000 the APA released four different versions of the Diagnostic and Statistical Manual of Mental Disorders, along with three updates to existing editions. The publication timeline for these medical reference texts is as follows:
- 1952: DSM-I
- 1968: DSM-II
- 1974: DSM-II Reprint
- 1980: DSM-III
- 1987: DSM-III-Revision
- 1994: DSM-IV
- 2000: DSM-IV-Text Revision
The most significant revision of the manual occurred as a part of the reprint of 1974, when in response to growing outrage from the public and from within the field the APA finally removed homosexuality from its list of mental disorders, reclassifying it vaguely as a “sexual orientation disturbance” (this label was abandoned six years later when the DSM-III was issued).
An Epidemic of Disease, or an Epidemic of Diagnoses?
In the DSM-I there were 106 distinct mental disorders listed, and this quantity has increased substantially over the years – the DSM-II included 182 separate disorders, the DSM-III listed 265, and the DSM-IV topped them all with a whopping 297 mental conditions deemed worthy of acknowledgement and treatment.
Here are a few of the reasons that have been most frequently offered to explain this dramatic expansion in the number of classified mental disorders:
- Mental health professionals have gotten better at diagnosing mental illness.
- More refined diagnostic techniques have allowed therapists to make distinctions between conditions that in the past were incorrectly grouped together based on superficial resemblances.
- Several studies have established that Americans really are suffering from more mental illnesses now than they did in the past (based on DSM-IV classifications, it is estimated that more than 46 percent of those currently living will experience some sort of recognized mental disturbance at some point in their lives).
This proliferation of mental conditions that are supposedly in need of therapeutic and/or pharmaceutical intervention has naturally generated much controversy, as many are convinced that this tripling in the number of distinct, diagnosable mental illnesses is evidence of a psychiatric profession run amok. Critics of the DSM accuse psychiatrists of promoting their own interests at the expense of everyone else (with the possible exception of the pharmaceutical industry, which is seeing its profits skyrocket as more and more drugs are prescribed to treat more and more “disorders”).
Whether these criticisms are accurate is open to debate. But one thing that can be said with certainty is that the individual medical professionals and the various psychiatric and psychological groups that have been involved in the DMS deliberation and negotiation process have slowly but surely moved away from the cautious inductive approach of the past and have adopted a deductive model to justify the classification of problematic perceptions, behaviors, and attitudes as mental disorders. The assumption that such variations in human mental life are at root medical problems with biological/neurological components that require heroic medical intervention (usually in the form of drugs, in coordination with intensive behavioral therapy) is seen as self-evident, and this belief has inevitably led to an explosion in the number of mental conditions listed in the APA’s official diagnostic manual. This transition was perhaps inevitable, based on the popularity of the DSM with clinicians and the apparent success of the psychiatric profession in bringing relief and comfort to millions of troubled individuals.
The Phoenix Will Rise
Ironically, a new and formidable challenge to the DSM has arisen from within the “mental suffering as disorder” camp. The federal government’s National Institute of Mental Health recently announced it will not sanction or recognize the new DSM-5, claiming that the science of mental illness has advanced far enough that we should be making diagnoses based on the study of brain states rather than psychological symptoms.
While many are predicting that the loss of government support will ultimately sound the death knell for the DMS classification system – or at least cause it to lose significant prestige – this move by the NIMH essentially validates the approach to mental illness pioneered by the framers and composers of the various versions of the Diagnostic and Statistical Manual of Mental Disorders. So even if the DSM’s influence declines in the years ahead, it will only bring the irony full circle, as a shift to biologically-based diagnostic techniques will actually strengthen the hold on the popular imagination of the ideology of mental disease and suffering that the psychiatric profession has been championing, through the DSM, for 61 years.