The Diagnostic and Statistical Manual
The Diagnostic and Statistical Manual
Over the past 50 years, the Diagnostic and Statistical Manual of Mental Disorders (DSM) has impacted the practice of psychiatry. The manual categorizes mental disorders in the United States (American Psychiatric Association, 2010). It is used in a wide array of contexts by clinicians and researchers in many different settings (Hospitals, clinics, insurance companies, etc). Initially, the DSM was developed from collected statistical information (Greenberg 2004). Through four revisions it has evolved to provide a common language and standard criteria for the categorization of mental disorders. Recently, controversial revisions of the DSM have been proposed and are currently under review. Is this new edition, the DSM-V, really needed and how valid and reliable is it and past manuals. Are the “disorders” in these manuals actually disorders? Is this manual merely a financial ploy by the American Psychiatric Association (APA), which holds the trademark for the manual, and drug companies whose products supposedly can help “control” or even “cure” these disorders? Are these disorders biases of society? No matter which or all of these concerns affect the development and practice of using of the DSM, one should consider how this manual shapes society or perhaps how society shapes this manual.
APA has devoted immense resources, scientists’ and clinicians’ time, expertise, and funds, to develop a scientifically and clinically based nomenclature that psychiatrists can use (Schatzberg 2009). In spite of all this research, however, there still seems to be much controversy in whether the disorders defined in the DSM are actually real conditions (Kendell 2003). With such vast arrays of diagnosis contained in the DSM, one must also wonder how proficient doctors are at diagnosing their patients. In the study “Being Sane in Insane Places” Dr. David Rosenhan, a researcher, not only demonstrated how dangerous dehumanizing and labeling in psychiatric institutions can be but also demonstrated that “abnormal” patients were able to pick out the same patients when doctors could not (Rosenhan 1973).
The experiment Rosenhan conducted was the first to scientifically look at normalcy between patients and everyday individuals in addition to inquiring about how diagnoses, which were based on the DSM, were being made and applied (Rosenhan 1973). The first part of the experiment involved the use of pseudopatients, a varied group of “normal” people (a psychology graduate student, 3 psychologists, a pediatrician, a psychiatrist, a painter, and a housewife). The pseudopatients faked auditory hallucinations in order to gain admission to 12 various psychiatric hospitals in the United States. They were successful in that they gained admission with a diagnosis. What was frightening, however, was that they remained in the hospital undetected by the staff at the psychiatric hospital as pseudopatients despite acting “normal” for the remainder of their visit (Rosenhan 1973). The second experiment involved the staffs at a psychiatric hospital who were asked to detect non-existent fake patients. The staff failed the experiment and falsely identified a large number of actual patients as imposters. These experiments demonstrated that it is not so easy to distinguish the sane from the insane in psychiatric hospitals.
The DSM has made no attempt to universally define normal and abnormal. The United States, where this manual is highly relied upon, is composed of people of various cultures. The psychiatrists and patients may be from different cultures. Cultures differ from one another and that what one culture may consider normal another may be seen as abnormal in another. For example, the DSM II initially classified individuals with homosexual preferences as mentally disabled. Since then, the DSM-III and current DSM have revised this categorization and no longer considered it to be a mental disorder. Although some jurisdictions in the United States have legally decided that this behavior is normal, others have not. In other countries, Vietnam, for instance, homosexuality is illegal and people can be prosecuted. If Vietnam had followed the DSM, these individuals would not be prosecuted. Therefore, perhaps it would be useful to define what is universally considered normal versus abnormal beyond cultural settings
The DSM primarily focuses on the signs and symptoms of abnormal behavior in order to facilitate the diagnosis of mental disorders. No one knows how these behaviors are generated. Allen Frances, chair of the DSM-IV task force, points out that “there can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders” (Frances 2009). The DSM is based on an underlying theory that assumes discrete medical disorders that can be distinguished from each other by symptom patterns; some have compared it to a naturalists field guide to birds or a cookbook (McHugh 2005). Not enough is known to structure the classification of psychiatric disorders according to etiology. The new DSM-V has been field tested as part of an iterative process which will test the some draft criteria and possible ramifications. It is peculiar that field testing for the DSM-V received no support from the National Institute of Mental Health. In addition, there will also be no draft of the DSM-V. Therefore, it seems that there “field trials” are no more than primary data collections that will have little say about how the DSM-V will do when applied in the field. Nevertheless, clarifying and defining what exactly constitutes each disorder is a work in progress.
The new DSM-V has some major changes including new categories to capture the milder sub-threshold versions of the existing more severe official disorders (Frances 2009). It will also contain 30 or more dimensional ratings which it claims will allow a clinician to rate the severity and subclinical diagnoses in addition to increasing the precision of diagnosis. The APA seeks to reduce the frequency of false negatives ultimately improving early case finding and promoting preventive treatments. This new approach seems great; however, I have several reservations about such drastic changes.
This new methodology requires more time and training. With such immense changes to the DSM and ambiguity in the results, one must wonder not only how patients will be affected but also how researchers and clinicians of different orientations will adapt. How much of a challenge it will be for them to adapt to this new system. With such drastic changes those who are technically qualified to use the manual may have trouble adjusting and cause more harm than good. Also, the dimensional ratings which already exist are often ignored, which leaves me to wonder if it will even be worth expanding the ratings (Frances 2009). Second, the intention of trying to reduce the frequency of false negatives may flood the world with new false positives. This could lead to a deluge of unneeded medication treatments that may ultimately lead to a high price in side effects, dollars, and stigma not including insurability, disability, and forensics. Finally, the field trials which have been conducted have not been extensive enough to predict the extent of false positive risks (Frances 2009). The changes being made seem extreme but because this field’s structure is ambiguous, that is that there is no biological evidence, experimentation is the only option in hopes of learning more about these mental illnesses.
The DSM should consider other disciplines (i.e. Anthropology, Biology, Chemistry, etc.) when preparing these editions. It should be more open in allowing other fields participate and contribute. By opening it up to other fields, it will help to avoid unforeseen problems that could arise. Since patients are dealt with by different types of people, it would be beneficial for all involved to know so that they might offer advice from another perspective. This could strengthen the field by helping to develop a better foundation and perhaps help find a more structurally sound foundation.
Although the DSM is not perfect, it has given some explanation of these ambiguous mental health diseases which have negatively impacted society. This growing field has taken the challenge by attempting to categorize every disease unlike other fields, which can rely on concrete evidence due to biology. Therefore, in those fields, a manual is not as important since they know what the source of the problem typically is. Since the mental health field is more abstract, it must be careful not to get caught up by stigmas and what society thinks is acceptable. Therefore, the DSM should take caution and be monitored so that it may avoid creating stigmas and try not to be culturally influenced, which is probably its biggest challenge. Nevertheless, the manual lays out what can be seen and should not be faulted for what society does with the information presented.
“DSM-V: The Future Manual.” American Psychiatric Association (2010): 1-2. American Psychiatric Association. Web. 29 Sept. 2010. <http://www.psych.org/mainmenu/research/dsmiv/dsmv.aspx>.
Frances, Allen, MD. “A Warning Sign on the Road to DSM-5: Beware of its Unintended Consequences.” Psychiatric Times 26.8 (2009): n. pag. Print.
Greenberg, S (2004). “Unmasking forensic diagnosis”. International Journal of Law and Psychiatry 27: 1-15. Doi: 10.1016/j.ijlp.2004.01.001 (http://dx.doi.org/10.1016%2Fj.ijlp.2004/01/001).
McHugh, Paul R. (2005) Striving for Coherence: Psychiatry’s Efforts Over Classification (http://jama.ama-assn.org/cgi/content/full/293/20/2526?ikjey=e5f8d881d7f6c0d853ce55elac5b693c5c53a950&keytype2=tf_ipsecsha) JAMA. 2005;293 (no.20)2526-2528.
Rosenhan, D L. “Being Sane in Insane Places.” Science 179 (Jan. 1973): 179-185. Print.
Schatzberg, Alan F, MD. “Some Thoughts on DSM-V.” Psychiatric News 44.16 (2009): 3. Print.