The newly revised Diagnostic and Statistical Manual of the American Psychiatric Association—DSM 5—has just been released at the Association’s annual meeting in San Francisco. Not since the critics uniformly declared Adam Sandler’s Jack and Jill ‘the worst movie ever made’ long before it actually was shown in a theater has something not yet put out in public gotten such full-throated critical panning. Consider some of the current headlines: “DSM 5: A Manual Run Amok” and my personal favorite, “Psychiatry’s New Diagnostic Manual: “Don’t Buy It. Don’t Use It. Don’t Teach It.“
It does not end there. There are also a flood of new books critical of the 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, just to name a few.
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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. It should really be called “The best we know so far about mental disorders” or perhaps “Our best effort to properly classify complicated human behavior.”
But a bigger problem is that the editors don’t know how to defend against the attacks. They keep saying that they are attentive to critics, that the process has been transparent and that they have posted draft versions online. But noting that anyone and everyone could comment on the drafts of DSM 5—and that more than 10,000 comments were received—makes the book sound more like a popularity contest than a scientific endeavor. Perhaps out of fear that the DSM 5 will not be seen as objective, the editors have stumbled in their defense of their work. But that doesn’t mean that a rationale doesn’t exist for what they have done.
The most common criticism is that the book proliferates diseases—kids who throw frequent temper tantrums are now afflicted with ‘Temper Dysregulation Disorder with Dysphoria,’ and those who are bereaved are lumped in with the depressed. Others critics note that Americans are over-medicated already and all DSM 5 does is provide more reasons to prescribe more pills. And some, such as the NIMH director Thomas Insell, argue that trying to lump and cluster symptoms without grounding them to hard causal evidence drawn from genetics and neurology is bound to create categories with no reliability or foundation.
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Lets 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 predicting the weather, climate scientists studying global warming, forestry experts, and those dealing with earthquakes do not have coherent explanations in atomic physics for their categories or for their causes. But their categories are accepted because they work—giving us predictable and actionable knowledge about the world. The same ought be the test of DSM 5.
As for proliferating diseases, the DSM 5 is, as critics note, making value judgments. What the editors need to do is embrace that fact, not run away from it in the hope of giving the book the appearance of eternal verity. It is a revision—there is no eternal verity to be had. Classifications, including those in mental health, change over time as our cultures and societies change. Get used to it.
The manual presumes that being an autonomous, self-governing, independently functioning person is a good thing and 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 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 tempers leads other kids and teachers to shun you, then your chance of becoming an independent person capable of social engagement may be diminished. Is it 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, coldsores, colds, osteoarthritis and dental cavities are just fine too.
Which leads directly to the other main gripe about DSM 5—the overuse of medications. There need not be a connection between a behavior or trait appearing in the DSM 5 and having your doctor write a prescription. If we really want doctors to stop prescribing so much medicine to us and our kids then we should stop asking them to do so, 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 drugging us.
The DSM 5 is not without flaws—it’s not yet linked to emerging research on genetics and neurology, for one. But the APA and the manual’s authors need to do a better job of explaining why it still has merit in that it captures key facts about human suffering, shows enough utility to be used by many professionals and patient from diverse background, and provides help to those who cannot function in a complex and rapidly evolving world. The mentally ill and the rest of us deserve it.