The field of psychiatry is abuzz these days with discussions about proposed changes to The Diagnostic and Statistical Manual. The next revision of the manual (DSM-V) is scheduled to be released in 2013 and it is already receiving a great deal of attention in and outside of psychiatry. Published by the American Psychiatric Association (APA), the DSM aspires to classify every mental health disorder known to man. Not only do mental health practitioners use it routinely, but insurance companies rely on it when making decisions about reimbursement. Consequently, any change to the manual will have important ripple effects throughout the field.
The Developmental History of the DSM
Some amount of controversy around the DSM is inevitable given its clinical importance. It was not always this way. In fact, the first DSM was published with little fanfare in 1952. A very similar manual, DSM-II was introduced sixteen years later and similarly created little stir. Both were widely regarded at the time as unreliable and their impact on psychiatry was minimal. It was not until 1980 with the introduction of the DSM-III that the manual gained traction and became the "bible of psychiatry." At the time, the DSM-III introduced a new set of criteria that helped guide clinicians in reliably diagnosing mental health disorders. This nosological shift had the positive effect of stimulating clinical research and improving communication across various mental health disciplines. The introduction of the DSM-IV (1994) and its subsequent revision (2000) were in many ways modest extensions of the diagnostic criteria captured by the third edition.
In the summer of 2007, a 27-member task force was appointed by the American Psychiatric Association to review and update the DSM. Chaired by Darrel Regier, MD, the Association's former Executive Director and head of its research division, the DSM-V Task Force immediately came under criticism for its overly ambitious and somewhat impractical approach to the task. Regier has touted the DSM-V as a "paradigm shift" in diagnosis; however, as many critics have warned, the current manual cannot support such a dramatic overhaul. In an eloquently written public statement released last year, Allen Frances, MD, the former chair of the DSM-IV Task Force, expressed serious reservations about the direction Regier and his colleagues are taking. Frances notes that many of the changes currently under consideration are scientifically premature and not supported by our nascent understanding of neurology and biochemistry.
DSM-V: Change Is Not Always a Good Thing
What is most alarming about the DSM-V Task Force is their almost paranoid need to conduct their work in secrecy. Critics have rightfully questioned the task force's unwillingness to provide transparency to the revision process. It was revealed that members were asked to sign confidentiality agreements that in practice would curtail free and open discussion among committee members and the public. Such secrecy runs counter to scientific inquiry and invites suspicion among the very individuals who are likely to be the manual's target audience.
The current DSM has done little to demystify mental disorders and the esoteric system created to diagnose them. The changes proposed by the current task force are only likely to further confuse and frustrate clinicians. Members are proposing that dozens of additional ratings scales be added to the DSM in an attempt to increase diagnostic precision. While there is certainly an advantage to such a dimensional approach, the practical reality is that busy clinicians do not have the time or inclination to place patients into arbitrary categories.
This leads me to my biggest concern about the forthcoming DSM-V. In an attempt to capture milder versions of already existing disorders such as schizophrenia and bipolar disorders, the DSM-V risks watering-down diagnoses to the point where they will no longer be clinically relevant. By lowering the threshold of what truly constitutes a mental disorder, proposed changes are likely to increase false-positive identifications (i.e., diagnosing individuals who do not actually have the disorder). This unintended outcome would provide credence to critics who already worry our profession is quick to pathologize clients.
The ramifications of such a liberal diagnostic approach would be profound. It would impact patients' insurability, not to mention increase the number of prescriptions being filled for psychotropic medication. It is the latter, which is of particular concern to me. Cynically, I suspect the pharmaceutical industry couldn't be happier with the proposed changes, as new consumers for pharmaceuticals will increase. And when you consider some of the new "mental disorders" being proposed by the task force (e.g., "Apathy Syndrome," "Internet Addiction," and "Parental Alienation Disorder" to name but a few) is it any wonder so many people are dismissive of our field?
Ironically, if left unchecked, the new DSM-V has the potential to do more harm than good. The task force, which was created to improve and build upon earlier versions of the manual, has strayed from their original mandate and are allowing politics (and perhaps even financial considerations) to dictate their agenda. If the direction of the DSM-V Task Force is not reigned in, than the best we can hope for is a diagnostic manual that will be irrelevant and at worst dangerous.
Tyger Latham, Psy.D. is a licensed clinical psychologist practicing in Washington, DC. He counsels individuals and couples and has a particular interest in sexual trauma, gender development, and LGBT concerns. His blog, Therapy Matters, explores the art and science of psychotherapy.