Psychiatry has been getting a lot of attention this month and it’s not because May marks Mental Health Month. The much anticipated release of the fifth edition of the Diagnostic and Statistical Manual (DSM) has been the focus headlines and criticism.
In 1980, the DSM-3 stirred great professional and public excitement by providing specific criteria for each mental disorder. It created a universal code of diagnosis amongst providers and facilitated treatment planning and revolutionized research. The public also became fascinated with the manual and it became a best-seller.
The DSM is a victim of its own success and is accorded the authority of a “bible” in areas well beyond its competence. It is often the primary determinant of treatment decisions, insurance eligibility, disability payments and who gets special school services. The DSM has long-driven the direction of research and from a forensic perspective carrying a psychiatric diagnosis could impose potential damage. This could range from loss of custody of a child, to loss of employment, to skyrocketing insurance premiums, and to loss of the right to make decisions about one’s medical and legal affairs. The manual is often used (and misused) in courts.
Critics of psychiatry’s newly released DSM-V diagnostic classification system have included the National Institute of Mental Health (NIMH), journalists, psychiatrists, and patients. Practically every major newspaper and magazine has been running opinion editorials on the DSM over the past year. For psychiatry’s more radical critics, psychiatric diagnoses are merely “myths” or “socially constructed labels.” There is a sense from the public and mental health professional communities that psychiatric diagnoses contribute to the “stigma” people feel when struggling through life’s problems. One of the major arguments against the DSM is that it lacks validity. Dr. Thomas R. Insel, director of the National Institute of Mental Health, has been quoted as saying, “As long as the research community takes the D.S.M. to be a bible, we’ll never make progress.”
Regardless of the DSM or its criticizers, psychiatry has indeed made a great deal of progress. Giving a patient a “diagnosis” means acknowledging when a person’s struggles impair their ability to function in life. For many patients, naming their illness helps to alleviate fears and uncertainties and contributes to their understanding and empowerment. In addition to a diagnosis, patients also receive a well-formulated treatment plan in which they are an active participant. Learning how to manage an illness gives a sense of control and creates feelings of hope and optimism.
Television and pop-culture have also recently domesticated mental illness. When TV heroes like Carrie Mathison (“Homeland”) struggle with bipolar disorder, or real-life stars like Catherine Zeta-Jones go public with it, mental illness becomes more acceptable and a sense of normalcy rather than stigma becomes attached.
The good news about the DSM-V, for supporters and critics, is that most psychiatrists will not take it too literally. We understand as did Sigmund Freud did that “the border between the normal and the abnormal is not as distinct as we think … There are many shades of gray.” People cannot fit neatly into a checkbox classification system. Psychiatrists appreciate this and will continue to approach each patient as a unique individual and together decide on the best treatment.