Singing the DSM-5 Blues

Arthur Caplan

The newly revised Diagnostic and Statistical Manual of Mental Disorders of the American Psychi-atric Association (APA)—DSM-5—was released this past May at the Association’s an nual meeting in San Francisco. Rarely has a new book met such a universal cacophony of critical reviews. Even before the tome had hit print, critics were falling over one another to knock the book. A sample of headlines assessing the work include: “DSM-5: A Manual Run Amok,” “Let’s Fight Big Pharma’s Crusade to Turn Eccentricity into Illness,” “DSM V: The Manual That Is Crazy,” and “Psychiatry’s New Diagnostic Manual: Don’t Buy It. Don’t Use It. Don’t Teach It.” And those were some of the friendlier assessments.

The negativity does not end with the reviews. There has also been a flood of new books devoted to ripping apart DSM-5, such as Gary Greenberg’s The Book of Woe: The Making of the DSM-5 and the Unmaking of Psychiatry; Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis by Allen Frances; and Allan V. Horwitz and Jerome C. Wakefield’s All We Have to Fear: Psychiatry’s Transformation of Natural Anxieties into Mental Disorders, to name only a few.

Now, there is plenty to kvetch about in the revised DSM. However, the critics are going way too far. The DSM is often described as “the bible of the mental health field”—an unfortunate misnomer that leaves it open to attack as a compendium of divinely inspired truths about human behavior. It should really be called The Best We Know to Date about What Constitutes Mental Disorders, or perhaps The Best Effort of a Group of Experienced Mental Health Clinicians to Properly Classify Complicated Human Behavior as OK or Suspect.

Perhaps an even bigger problem is that the editors of DSM-5 don’t know how to defend themselves against the attacks. They keep saying that they were attentive to critics during the drafting of the revised volume, that the process has been transparent, and that they had posted draft versions online for all who cared to whale away at. But noting that anyone and everyone could comment on the drafts of DSM-5—more than ten thousand comments were received—makes the final contents of the book sound more like the results of a popularity contest than a scientific endeavor.

The editors are terrified that DSM-5 will not be seen as objective. This raging fear is also omnipresent in the comments of the critics—the book is not “objective,” some say, and it represents instead a sour stew of professional elite values, intolerance of eccentricity, manipulation by powerful drug companies looking to push products, and a self-interested dream to get each and every one of us a diagnosis that requires treatment by the editors of the book and their cronies. The editors don’t seem to know what to say in response to these claims other than that the revision process was transparent. But that doesn’t mean that a rationale doesn’t exist for what they have wrought.

The most common criticism in the reviews and books is that DSM-5 proliferates diseases beyond the boundaries of common sense. Children who once threw frequent temper tantrums are now afflicted with “Temper Dysregulation Disorder with Dysphoria.” Those who are bereaved due to the loss of a loved one or a pet are lumped in with the clinically depressed. Many critics note that Americans are overmedicated already and that all DSM-5 does is provide more reasons to prescribe more pills. Grieving the loss of your parent? Take a pill!

The critics of DSM’s rich taxonomy of mental miseries are not all outside psychiatry. Some, such as Thomas Insell, the director of the National Institute of Mental Health (NIHM), are very mainstream. Insell argues that trying to lump and cluster symptoms without grounding them in hard causal evidence drawn from genetics and molecular neurology is bound to create categories with no reliability or foundation.

Let’s get rid of that last complaint first. The view that the only medical classifications that are valuable are those grounded in molecular biology can be dismissed out of hand. Meteorologists, climate scientists, forestry experts, and specialists who work to identify floodplains or predict earthquakes can seldom offer coherent explanations in atomic physics or quantum theory for their subjects of study or for their causes. Their systems of categories and classifications are accepted because they work—giving us actionable knowledge about the world. The same ought to be the test of DSM-5.

As for proliferating diseases, DSM-5 is, as critics note, making value judgments. What the editors and the rest of us need to do is embrace that fact. DSM-5 is a revision—by definition, there is no eternal verity to be had. Classifications, including those in mental health, change over time as our culture, technology, and societies change. Get over it and get used to it.

So what sort of values is DSM-5 foisting upon us? The manual presumes that being an autonomous, self-governing, independently functioning person is a good thing and that creating children who can mature this way is also a good thing. But that doesn’t turn the manual into a plot by drug companies and their henchmen to impose a drug-addled way of life on the rest of us. The capacity to lead one’s life and flourish happens to be a guiding principle in America today and in most parts of the world. Not every culture holds this view; nor has this been a primary value throughout history. But, if grief makes it hard for you to function, then you have a disorder. If having frequent temper tantrums leads other students and teachers to shun you, then your chance of becoming an independent person capable of social engagement may be diminished. If you cannot stop watching porn on your computer and as a result neglect your family or your job, that spells disorder. It is easy to take potshots when what used to be normal or ignored is now categorized as illness, but treating what is “normal” as disease is wrong only if you think acne, rashes, fevers, warts, cold sores, colds, cancer, osteoarthritis, and dental cavities are just fine too.

Which leads directly to the issue of overuse of medications. There need not be a connection between a behavior or trait appearing in DSM-5 and having your doctor write a prescription. If we really want doctors to stop prescribing so much medicine to us and our families, then we should stop asking them to do so. We ought to bring direct-to-consumer advertising to an abrupt halt, slap a steep co-pay on elective drug use, and start paying doctors to talk to us instead of drug us.

DSM-5 is not without flaws—it is not yet linked to emerging research on genetics and neurology, for one. There will be time for that, given the elementary knowledge we now possess about the brain’s connections and composition. For their part, the APA and the manual’s authors need to do a better job of explaining that the DSM still has merit in that it captures key facts about human suffering, shows enough utility to be used by many professionals and patients from diverse backgrounds, and provides ways to help those who cannot function in a complex and rapidly evolving world. The mentally ill and the rest of us deserve at least that much. We shouldn’t have to face a mountain of scorn and derision for seeking help when we cannot stop crying when Fluffy or Fido pass on.

 

Arthur Caplan

Arthur Caplan is director of the University of Pennsylvania’s Center for Bioethics and a nationally prominent voice in the debates over cloning and other bioethical concerns.


The newly revised Diagnostic and Statistical Manual of Mental Disorders of the American Psychi-atric Association (APA)—DSM-5—was released this past May at the Association’s an nual meeting in San Francisco. Rarely has a new book met such a universal cacophony of critical reviews. Even before the tome had hit print, critics were falling over one another …

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