Thoughts on the Diagnostic Statistical Manual (of Psychiatric Disorders)

In May 1817,  the first mental health hospital in the U.S. was founded in Philadelphia by a group of Quakers. Known as The Asylum for the Relief of Persons Deprived of the Use of Their Reason,  today it still stands as the Friends Hospital.

When it was founded, mental illness was widely misunderstood and treated as criminal behavior. Mentally ill people were tied up, put in chains, isolated, and/or beaten.

I’m posting this week’s blog from San Francisco at the annual meeting of the American Psychiatric Association, where

almost two hundred years to the day of the founding of the first mental hospital in the U.S., the fifth edition of the DSM-5 of the American Psychiatric Association makes its debut.

The initial impetus for developing a classification of mental disorders in the US was the need to collect statistical information. In this regard, it has been a colossal failure. To my knowledge, none of my colleagues regard this manual as a tool of statistics. Rather, we use it in obligatory ways to interface with various systems like health insurance companies,

Like me, many of my colleagues regard the protection of the patient as more important than statistical correctness. We don’t choose a diagnosis that may interfere with employment opportunities, unless, of course, the individual is unable to work.  We serve as allies, not adversaries, of our clients.  Furthermore, accuracy in diagnosing a psychiatric “disorder” on the basis of phenomenology, or observation of symptoms, is subjective and changeable.

The good news is that we no longer categorize mental disturbances as “criminal behavior.” We continue to elucidate the complex mechanisms of the intricate brain in order to decipher the nature of mental suffering.

Although the DSM has attracted praise for standardizing psychiatric diagnostic categories, it has also unleashed torrents of controversy and criticism for an unscientific system that has been said to enshrine the opinions of a few powerful psychiatrists.

Other criticisms include: ongoing issues about validity and reliability of the diagnostic categories; the reliance on superficial symptoms, and the use of artificial lines dividing  diagnoses from “normality.”

In general, psychiatrists are not enamored of any editions of this manual; I think I speak for many of my colleagues when I say we regard its existence as a necessary evil at this point in our evolution. In another hundred years, it may be categorized as a relic along with the chains, ice picks and bloodlettings of previous centuries.  

By design the DSM is primarily concerned with the signs and symptoms of mental disorders, rather than the underlying causes. It claims to collect and organize them based on statistical or clinical patterns. As such, it has been compared to a naturalist’s field guide to birds, with similar advantages and disadvantages. The lack of a causative or explanatory basis, however,  is not specific to the DSM, but rather reflects a general lack of patho-physiological understanding of psychiatric disorders.

Each of us humans is unique and less predictable than any animal on earth and therefore won’t fit neatly into a diagnostic label.

On April 29, the director of the National Institute of Mental Health (NIMH), Thomas Insel, announced that the lack of validity of the D.S.M. was limiting progress in mental health research. Less than two weeks “after throwing DSM under the bus,” he issued a joint statement with APA President-elect, Jeffrey Lieberman. DSM, they wrote, “represents the best information currently available for clinical diagnosis of mental disorders.”

Gratefully President Obama is allotting funds for research on the brain. An elucidation of the neurosciences will benefit us all.

Conclusion: Good-enough psychiatrists relate to the individual, to build a working alliance, regardless of diagnostic category, and to elucidate and minimize obstacles that interfere with a constructive and satisfying life.

We have come a long way since 1817; we’re on the path of the neurosciences to discover the underlying mechanisms of  “phenomenology.” In the meantime, patience and an open mind to change will ease our journey.

Dear Reader: I welcome your opinions. Jsimon145@gmail.com