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Many people want to know why misophonia is not in the DSM, or are curious as to how we can get misophonia into the DSM.
As you may know, the two most widely used manuals are the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and the International Statistical Classification of Diseases and Related Health Problems (ICD-10). Both manuals aim to describe disorders in concrete ways so that doctors have a standardized way to make diagnoses. The ICD-10 is an international manual managed by the World Health Organization. The DSM-5, currently in its fifth iteration, is published by the American Psychiatric Association.
As people with misophonia, we have to think about what it means if and when misophonia gains entry into the DSM. The DSM wields great power in regard to insurance reimbursement for “mental disorders.” Clearly, for this purpose, we want to see misophonia in the DSM. However, there are numerous other ways in which this manual impacts our lives, and the lives of our loved ones. Most people don’t know how far-reaching the DSM is.
The DSM has been translated into over 20 languages. It is referred to by clinicians from multiple disciplines, as well as researchers, policymakers, criminal courts, and of course, third-party reimbursement entities. It is safe to say then that DSM-5 has a monopoly on psychiatric diagnosis.
Despite the obvious benefits of insurance reimbursement, one wonders how appropriate it would be for misophonia to be in the DSM, a manual whose purpose is the classification of “mental disorders.” While the DSM does include developmental and learning disorders, the way we conceptualize misophonia may be negatively affected by its association with this diagnostic manual. As Edward Shorter states in a 2015 article published in Dialogues in Clinical Neuroscience, “It would be easy to think that the … DSM-5 evolved as a logical and scientific progression from DSM-IV. In fact, it evolved in a haphazard and politically driven manner from a century and a half of effort to get the classification of psychiatric illness right.”
Here is a little DSM history:
The first edition of the DSM was published by the APA in 1952. Both DSM-I and DSM-II were largely driven by psychoanalytic theory. Beginning with Sigmund Freud in the late 19th century, psychoanalytic theory focuses on the conflicts between different elements of the personality, most of which operate within the subconscious mind. Psychoanalysis, the treatment based on psychoanalytic theory, seeks to reorganize personality by bringing an individual’s unconscious motivations into the conscious mind in order to resolve inner conflicts. Within this paradigm, specific diagnostic entities were limited. (The DSM-I was 130 pages long and listed 106 diagnoses.) Disorders were grouped into two categories, one based on impairment of the brain tissue, the other not based on any identifiable physical characteristic in the brain.
Unfortunately, both psychoanalytic theory and the DSM precede the advent of neuroimaging, as well as advanced understandings of genetics and general medicine. In fact, neuroscience was only formally established as a unique field of study at Harvard University and at the University of California, Irvine in the mid-1960s. This necessarily created a pitfall of medical inaccuracy in the first and second iterations of the DSM. Despite this, however, in these manuals, diagnosis took a backseat to the therapeutic relationship between doctor and patient. These two manuals viewed symptoms as reactions to inner conflict and the outside world, as opposed to evidence of discrete disorders.
By 1980, however, the APA resolved to update the way in which mental disorders were classified to be more in sync with modern medicine. However, when looking at the supposedly medical DSM-III, you may ask, “Where is the science?” DSM-III was 494 pages, with 265 diagnoses (compared to DSM-II, which was 134 pages long with 182 diagnoses). What accounted for this growth? One would hope that the 1980 DSM, with its claim to be medically based, might have integrated some of the recent advances in genetics and neuroscience.
However, the DSM-III simply switched from a psychodynamic to an empirical model. In other words, the manual changed from a psychodynamic perspective, based on theories of the unconscious, to a more behavioral perspective, based on observable characteristics and behaviors. Unfortunately, the problem has only become worse as DSM editions have updated.
For example, the DSM-5’s removal of Asperger’s Disorder caused a great deal of disagreement within the medical community and upset amongst those diagnosed with Asperger’s. In the DSM-IV, Asperger’s was characterized by difficulty with socialization and language pragmatics (e.g. the way context contributes to understanding conversations). Over 15+ years, thousands of people received a diagnosis of Asperger’s Disorder and naturally integrated that into their personal identity. Then, with the advent of the DSM-5, Asperger’s simply no longer exists. Numerous autism and Asperger’s experts actually resigned from the DSM-5 committee.
Yet, the DSM-5 text states, “Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger's disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder.” This decision had a profound effect on the lives of those formerly diagnosed with Asperger’s.
We take diagnostic labels and manuals as if they were “etched in stone.” We often think that there exists an authoritative force, an all-knowing omnipotent being (or group of beings) that actually know how to classify mental health disorders. However, the classification of disorders is a very difficult process and we cannot simply blame the DSM committees.
It is interesting to note that the National Institute of Mental Health (NIMH) parted ways with the DSM during its last revision. The NIMH has been working on a more process-based way of diagnosis. This effort is titled the Research Domain Criteria (RDoC) and includes various domains including the cognitive, regulatory, and sensorimotor systems to name a few. The RDoC integrates modern neuroscience and genetics as well. It is a less biased and perhaps biasing system. Yet, it is very complicated to create, maintain, and use. While the NIMH awards grants on the basis of the RDoc, we still rely on the DSM-5.
The differentiation of misophonia as a neurological rather than psychiatric disorder is important to those who have the disorder and to those who research and treat it. It is possible that the next DSM edition might have room for these distinctions. Yet, this is still an unknown and something we all need to be aware of.
For workshops on Misophonia, see Misophonia and Co-Occurring Disorders and Coping With Misophonia-Sensation and Emotion.
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