DSM-5…it’s not the bible

“Just because your doctor has a name for your condition doesn’t mean he knows what it is”

                                                                                                                                                                                          -Arthur Bloch

As many of you know, this month we will see the publication of the 5^th edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM-5) by the American Psychiatric Association. Often referred to as the “bible” of mental health, DSM provides symptom criteria for hundreds of behavioral health conditions, from schizophrenia to autism to depression.

This most recent iteration of the DSM has been deeply contentious for many reasons. People are upset about what is left out (Asperger’s Disorder), concerned that this may lead to a de-legitimization of a real condition, to loss of eligibility for special education and social services, and to reductions in research funding. People are also upset about what is being added (Disruptive Mood Dysregulation Disorder), fearing that it will over-pathologize normal behaviors and lead to excessive diagnosis and treatment.

Lost in the noise is a realistic sense of what DSM really is. The original problem that DSM was intended to address was the lack of consistency in terminology among mental health professionals. Years ago, the term “depression” might be used in many different ways. A Freudian psychiatrist might mean one thing by the term, a behavioral psychologist another. Lack of terminological consistency makes it impossible to move science forward; I might publish a study on “anxiety”, but how can you replicate it or apply it to your work if we have different understandings of what that word means?

DSM provides concrete, clear, black-and-white definitions of these terms so that there is consistency in their use. That is its purpose. It does not tell us what CAUSES depression or anxiety; what the proper TREATMENTS for schizophrenia are; or what the PROGNOSIS might be for a child with autism. In a recent talk that I gave to the Federation for Children with Special Needs I described it as simply a “dictionary”, a metaphor echoed in a recent online post by Dr. Thomas Insel, the director of the National Institute of Mental Health (click here for his piece). Dr. Insel provides an excellent critique of the DSM-based system of classification and outlines a plan on the part of his agency for developing a more comprehensive approach. Achieving consistency in language is an important step, but we need to move beyond it. We can’t continue to define and classify these terms on the basis of surface symptoms.

The furor over DSM-5 also raises another issue. In many aspects of life we feel that by naming something we make it “real”, and mental health is no different. Conversely, removing a name may make it seem as if something is no longer real or legitimate. Certainly, inclusion of a diagnosis in the DSM has “real world” implications in terms of insurance coverage and service eligibility. We have to remember, however, that simply by developing a label and listing symptom criteria we have not understood the individual to whom the label is applied. That understanding, which is the goal targeted by Dr. Insel and NIMH, will require that we push beyond surface symptoms to understand the “bones” of a disorder – and to do that we need to remember what DSM is, and more importantly what it is not.