Image: Illustration by Patrick George
In Brief
- The fifth version of psychiatry’s bible, the Diagnostic and Statistical Manual of Mental Disorders, slated for publication in May 2013, represents the first substantial change to psychiatric diagnosis in more than 30 years.
- In 2010 the American Psychiatric Association debuted a draft of the new manual on their Web site that has so far received 50 million hits from about 500,000 individuals, many of them critics.
- The revised manual will very likely scrap psychiatry staples such as Asperger’s syndrome and paranoid personality disorder.
- Additions to the diagnostic menu are likely to include an ailment for children marked by severe temper tantrums and for adults a type of sex addiction.
Editor's Note: Read our blog series on psychiatry's new rulebook, the DSM-5.
In February 1969 David L. Rosenhan showed up in the admissions office of a psychiatric hospital in Pennsylvania. He complained of unfamiliar voices inside his head that repeated the words “empty,” “thud” and “hollow.” Otherwise, Rosenhan had nothing unusual to report. He was immediately admitted to the hospital with a diagnosis of schizophrenia.
Between 1969 and 1972 seven friends and students of Rosenhan, a psychology professor then at Swarthmore College, ended up in 11 other U.S. hospitals after claiming that they, too, heard voices—their sole complaint. Psychiatrists slapped them all with a diagnosis of schizophrenia or bipolar disorder and stuck them in psychiatric wards for between eight and 52 days. Doctors forced them to accept antipsychotic medication—2,100 pills in all, the vast majority of which they pocketed or tucked into their cheeks. Although the voices vanished once Rosenhan and the others entered the hospitals, no one realized that these individuals were healthy—and had been from the start. The voices had been a ruse.
The eight pseudopatients became the subject of a landmark 1973 paper in Science, “On Being Sane in Insane Places.” The conclusion: psychiatrists did not have a valid way to diagnose mental illness.
Rosenhan’s experiment motivated a radical transformation of the essential reference guide for psychiatrists: the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA). The revamped DSM, dubbed DSM-III and published in 1980, paired every ailment with a checklist of symptoms, several of which were required for a diagnosis to meet the book’s standards. Earlier versions of the DSM contained descriptive paragraphs that psychiatrists could interpret more loosely. This fundamental revision survives today.
The APA is now working on the fifth version of the hefty tome, slated for publication in May 2013. Because the DSM-IV was largely similar to its predecessor, the DSM-5 embodies the first substantial change to psychiatric diagnosis in more than 30 years. It introduces guidelines for rating the severity of symptoms that are expected to make diagnoses more precise and to provide a new way to track improvement. The DSM framers are also scrapping certain disorders entirely, such as Asperger’s syndrome, and adding brand-new ones, including binge eating and addiction to gambling.
In the past the APA has received harsh criticism for not making its revision process transparent. In 2010 the association debuted a draft of the new manual on its Web site for public comment. “That’s never been done before,” says psychiatrist Darrel Regier, vice chair of the DSM-5 Task Force and formerly at the National Institute of Mental Health. The volume of the response surprised even the framers: 50 million hits from about 500,000 individuals and more than 10,000 comments so far.
Critics swarmed the drafts. Some psychiatrists contend that the volume still contains more disorders than actually exist, encouraging superfluous diagnoses—particularly in children. Others worry that the stricter, more precise diagnostic criteria may inadvertently give insurance companies new ways to deny medication to patients who need it.
The debates surrounding the manual’s revisions are not merely back-office chatter. Although many psychiatrists do not sit down with the DSM and take its scripture literally—relying instead on personal expertise to make a diagnosis—the DSM largely determines the type of diagnoses clinicians make. Insurance companies often demand an official DSM diagnosis before they pay for medication and therapy. Many state educational and social services—such as after-school programs for kids with autism—also require a DSM diagnosis. Consequently, psychiatrists cannot dole out diagnoses of their own invention. They are bound to the disorders defined by the DSM.
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16 Comments
Add Comment"Although many psychiatrists do not sit down with the DSM and take its scripture literally..."
Reply | Report Abuse | Link to thisThis is an important caveat. And it illustrates why more attention needs to be drawn not to what's in the book, but how the book is used.
As a practicing psychiatrist, I agree with you that many clinicians "rely on personal expertise to make a diagnosis." What we are forced to write in the chart, however, is dictated by the DSM. From that point on, the diagnosis-- NOT the patient-- becomes the focus of treatment. It serves as a gateway not only to a wide range of social services-- which could be beneficial-- but also to a potential lifetime of medication trials and other ill-advised treatments.
Most psychiatrists view the DSM and the diagnostic process as a necessary evil: "necessary" for reimbursement and to be able to help the people who seek our assistance, but "evil" because in many systems the assistance we provide is dictated by the diagnosis, not by the unique needs of the individual.
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Reply | Report Abuse | Link to this"Residual: very few typical symptoms but some odd beliefs or unusual sensory experiences."
Reply | Report Abuse | Link to thisThat describes most of the people I know.
The DSM is nothing more than a piece of trash. These so called conditions were made up from a committee of "scientists" the majority of whom have financial connections to drug companies. These companies are drooling over the fact that new markets will be open to them to sell more worthless and harmful drugs. There is absolutely NO scientific basis for the conditions included in the DSM. This is nothing more than a sham to make insurance companies pay for more drug therapy at an astronomical increase in cost.
Reply | Report Abuse | Link to thisQuote: In the past the APA has received harsh criticism
Reply | Report Abuse | Link to thisAnswer: "I have lived a full, interesting and creative life supported by my family and many friends and irritated and spurred on by the hostile criticisms of a group of psychiatrists representing APA and NIMH."
Those words were spoken by Dr. Abram Hoffer , 'father of Orthomolecular Psychiatry'.
http://orthomolecular.org/history/hoffer/index.shtml
"Catatonic schizophrenic"
"Left in a coma and was dying"
"The next day he sat up and drank it and thirty days later he was well. He was discharged and remained well"
The American Psychiatric Association advocates AGAINST the use of the treatment above.
The American Psychiatric Association MUST be harnessed and their powers removed.
I was a psychiatric RN, with an MA in counseling for twenty years. I agree on your comments. I have also seen that various diagnoses have been given to the same patient on different admissions, even though no symptoms have changed. Psychiatrists should be able to focus on the patient as an individual. Unfortunately some do not, and most psychiatry relies more on medication, with a minimal amount of counseling.
Reply | Report Abuse | Link to thisSo, ironjustice, all you have is a story from the website of orthomolecular.org itself?
Reply | Report Abuse | Link to thisEven if it's true, it occasionally happens that people wake up from a coma for no discernible reason. One case is not statistically significant.
...What happened to my name?
Reply | Report Abuse | Link to thisTest: ć
"Schizophrenia is characterized by a tenuous grasp of reality, difficulty thinking and speaking clearly, and unusual emotional responses."
Reply | Report Abuse | Link to thisCan we use this diagnosis for political parties? Pretty please with sugar on top?
But seriously. Opening the process is probably a good thing. But does it go far enough? AFAIK, the DSM was originally a collection of random wisdom from a bunch of doctors. It was unexpectedly a best seller. Arguably, it's long past time to put some science into it. One hears phrases like "evidence based medicine". How would that work with the DSM? Maybe pilot projects. One publishes a DSM for Wayne County, and another for Macomb County. Figure out the pluses and minuses of each through use, and apply the results to the next pilot projects. Results are only expanded to larger populations when the desired outcomes are maximized. No politics. No vested interests. This isn't easy, but it appears that there is a mandate.
If religion had to undergo as massive and dramatic an overhaul as this, devotees of "science" would roundly denounce it. In fact, "psychiatry", "psychology", "psychoanalysis" all have traits that utterly disqualify them much less than as "scientific", but even as useful. Consider that all "psychoanalytic theories" are definitively different, if not wholly incompatible. Freud's emphasis on sex, Fromm saying a desire for conformity and programming defines man, Skinner saying everything is already programmed, Jung invoking already defined stereotypes. And all supposedly describing the same human mand! And yet no devotees of "science" attack "psychology" as a fraud! They respect the money, not ethics! Just as in the case of the single most accusatory quality of "psychoanalysis". Claiming to be a modeling of all human minds, "psychoanalytic theories" all derive solely from case histories! All "psychoanalytic theory" is based on individuals with proven mental instabilities, yet, they try to generalize from these to healthy minds! No "psychoanalytic theory" recognized by "science" derived from interviewing sane people!
Reply | Report Abuse | Link to thisDave , there is no room to place much of his 600 published works. The fact you seem not to know anything OTHER than that which I have placed , one article , means ? You don't have the gear to be commenting.
Reply | Report Abuse | Link to thisWhat evidence do you have of this alleged interference from drug companies? That's a strong accusation to make blindly.
Reply | Report Abuse | Link to thisI've often thought it's very ironic that "science-based" critics of alternative medicine ignore therapists and psychologists, who *really* have little or no research support for much of what they do. Psychiatrists might practice somewhat more science-based medicine, but still deserve criticism from a science-based point of view.
Reply | Report Abuse | Link to thisQuote: what evidence
Reply | Report Abuse | Link to thisAnswer: Depakote.
600? So? L. Ron Hubbard published far more.
Reply | Report Abuse | Link to thisQuite the generalization, that is.
Reply | Report Abuse | Link to this