DSM 5 controversies and a ‘novel’ reading of its contents

Published by the American Psychiatric Associat...
Published by the American Psychiatric Association, the DSM-IV-TR provides a common language and standard criteria for the classification of mental disorders. (Photo credit: Wikipedia)

The new Diagnostic and Statistical Manual, version 5 was released in May, attended by DSM 5 Controversies in the media, blogs and the academic literature (see this also).

Thomas Insell (Director of the NIMHcomments that

The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

Insell further states that:

Patients with mental disorders deserve better. NIMH has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system.

This piece (Future of DSM – V: Neuroscience, Clinical Evidence, and the Future of Psychiatric Classification in DSM -5) was a useful portent of the problems to come.

However (and this depends on your sense of humour), possibly the funniest treatment of DSM5 is this review which treats the Manual as a pomo novel:

[DSM 5] is a story without any of the elements that are traditionally held to constitute a setting or a plot. A few characters make an appearance, but they are nameless, spectral shapes, ones that wander in and out of view as the story progresses, briefly embodying their various illnesses before vanishing as quickly as they came – figures comparable to the cacophony of voices in The Waste Land or the anonymously universal figures of Jose Saramago’s Blindness

I think there is some value in taking a review like this seriously for teaching purposes (if not for research), as it will require students to take an entirely different view of the document at hand – no bad thing in itself. I continue to mostly use DSM4-rev, while referring to 5: 4-r is mostly without the controversies attending 5 and has the benefit of being widely used in the literature (the value of which can be underestimated – at least if we’re all wrong, the degree of bias will be largely in the same direction). It is difficult to imagine a DSM 6 appearing that will be anything like 5. It is also difficult to imagine anyone having the energy to revisit this abstruse but consequential nosological issue anytime soon.

Update: having just had a coffee with my lunch, I thought I would have to quote the following from the essay:

The entry on caffeine intoxication disorder informs us, with every appearance of seriousness, that the diagnostic criteria include “recent consumption of caffeine” along with “1) restlessness 2) nervousness 3) excitement.”

Seriously?! Due doppio espresso per me!

Author: Shane O'Mara

Neuroscientist

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