Welcome to Matters of the Mind, a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition.
You’re feeling down. But do you have a low mood because you’re dealing with the loss of a loved one, a break-up or divorce, or abusive co-workers? Or are you suffering from a depressive disorder: a recognised mental illness caused by an imbalance in the neurotransmitters in the brain, for which a variety of effective medical treatments are available?
Modern psychiatry no longer views our low moods as misguided reactions to life’s challenges. Instead, negative emotions are seen as biomedical problems which often require a prescription. This fundamental change in psychiatry occurred in the 1980s, when we shifted from the second to the third edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (the DSM).
DSM-I and II
After World War II, there were two kinds of psychiatrists: some ran large mental hospitals which housed great numbers of individuals with severe and persistent forms of mental illness; others were psychotherapists, supporting relatively well individuals who were facing unusual challenges or who were stuck for one reason or another. Psychiatrists thought the problems of this second group were related to what was happening in their lives — or their misguided, exaggerated, or misinformed reaction to that.
The DSM-I and II addressed the needs of both groups. There was a section on severe forms of mental illness (useful for mental hospital psychiatrists) and a section on the disorders of normal people containing a fair amount of psychodynamic jargon (for the worried well). The DSM was useful for collecting statistics and for standardising approaches. At the time, psychotherapy was considered an art — and diagnosis was only one element of that art.
Everything changed with the third edition of the DSM. The authors felt it was time to clean up the manual: out with psychoanalytic mumbo jumbo, in with scientifically proven diagnostic categories.
Because the cause of most mental illnesses was still shrouded in mystery, the aim was to present neutral descriptions of symptom patterns as the basis for psychiatric diagnosis. (This, by the way, made psychiatric diagnosis different from diagnosis in all other medical specialities, where physicians rely on objective physical findings and medical tests, and not only on the observation of symptoms.)
The categorical view embodied in DSM-III assumed that mental disorders are discrete entities that can be defined by specific sets of symptoms. And that, of course, is still an open question.
In clinical practice, DSM-III led to a “Chinese menu” approach to psychiatric diagnosis: a specific mental illness can be diagnosed if a sufficient number of boxes can be ticked. This is only of limited value in clinical practice.
Psychiatric research indicates that things are more complicated than the manual leads us to believe. In reality, many diagnostic categories overlap. Over the years, many new diagnostic categories have been proposed. As a consequence, many individuals now fit several diagnostic labels. Should their different disorders all be treated separately, or at the same time?
Because every individual patient tends to present a unique constellation of symptoms, many practising psychiatrists use an “escape category” and diagnose their patients with a particular disorder not otherwise specified. This sub-category is unusually popular in clinical practice, indicating that all the other sub-categories do not fit the bill.
Clinical experience indicates that most presentations of mental illness can be located on a spectrum. So a dimensional rather than a categorical approach might be more useful. But unfortunately, it is much more difficult to write a dimensional manual.
One reason to reorganise the psychiatrists’ bible so thoroughly was to facilitate pharmacological research for mental disorders. In 1954, chlorpromazine was introduced for the treatment of schizophrenia. To investigate its effectiveness, it was necessary to standardise diagnostic practices across mental hospitals.
According to psychiatric statistics at the time, the prevalence of schizophrenia was three times higher in the United States than it was in United Kingdom, where patients were diagnosed with manic-depressive illness much more often. Clearly, something was amiss.
DSM-III contained a promise: once reliable diagnostic categories were adopted, fruitful medical research into the nature of mental illness could be conducted. To the proponents of DSM-5 (to be released in May 2013), this promise has been more than fulfilled. A great number of new diagnostic categories have been defined while many others have been refined or discarded.
To the critics, things appear much more problematic. According to them, psychiatric research is tainted because it is paid for by multinational pharmaceutical companies to create a market for their drugs.
Widening the net
The number of individuals who meet the diagnostic criteria of the latest edition of the manual is growing steadily. Biological psychiatrists have increased the number of diagnostic categories that cover behaviours and emotions which, until recently, were considered to be normal. The number of fidgety or dreamy kids on Ritalin and the number of moody adults on antidepressants has never been higher.
Despite its many promises, the biological approach to mental illness has only achieved a limited amount of success. Critics have argued that the symptom-based approach of the current DSM does not take life events into account. It could be that helping individuals to deal with the circumstances of life is more fruitful than medicalising human distress.
This is the first part of our series Matters of the Mind. To read the other instalments, follow the links below:
Part seven: Redefining autism in the DSM-5