When is sadness depression? Is obsessive compulsive disorder just another term for excessive cleanliness and good organizational skills? Can a child's temper tantrum ever be classified as a mental disorder? The answers to these questions are as enigmatic as the field of mental illness itself: sometimes, maybe, and depends on who you ask. For a mental health clinician, however, there is one book that was created to answer all these queries: The Diagnostic and Statistical Manual of Mental Disorders. This week, the fifth edition was published.
Known as the DSM-5, the newest edition of the Diagnostic and Statistical Manual of Mental Disorders is, like its predecessors, meant to update and revise the tool most often used by psychiatrists to diagnose patients. The DSM-5, researched and published through the American Psychiatric Association, is the result of more than a decade of investigation, testing and field studies of various mental health disorders. With this research, the American Psychiatric Association has created the DSM-5: A 947 page manual detailing symptoms and diagnostic recommendations for over 300 mental disorders.
With the DSM, psychiatrists and other mental health physicians can classify a patient based on his or her symptoms, and use that diagnosis to find an appropriate course of treatment. Many psychiatrists consider the DSM a sort of bible - it is the only diagnostic tool of its sort available to doctors working in the field of mental health.
However, the DSM has long been a source of controversy amongst members of the mental health community, and before the DSM-5 had even been released, some medical professionals were already voicing their disapproval of the updated manual.
In a May 6th interview with the New York Times, director of the National Institute of Mental Health Dr. Thomas R. Insel expressed his disappointment that during their ten years of research in updating the DSM, the American Psychiatric Association focused only on studying the symptoms of mental illnesses, rather than their root causes. Insel is an important figure in the field of mental health, and has stated many times his wish for better research on the scientific, biological causes of mental illness; examining neuroscience and genetics rather than diagnosing a collection of symptoms and calling it a disease.
Other mental health spokespeople agree that the new DSM, like the manuals that came before, may put too much emphasis on symptoms rather than causes of mental illness. Dr. Steven E. Hyman, a psychiatrist and neuroscientist at the Broad Institute and a former director at the National Institute of Mental Health, was also interviewed earlier this month by the New York Times. In his comments, Dr. Hyman points out that diagnosing mental illness based on symptoms alone (rather than using, say, a definitive genetic test or brain scan) can lead to many problems. One such problem is the fact that a patient's symptoms may be so broad that it is unclear which mental disease that person is suffering from. If a man comes to his psychiatrist with constant nervousness, an obsessive need to check his locks before leaving the house, and frequent panic attacks, should this man be diagnosed with anxiety disorder, obsessive compulsive disorder or panic disorder?
As stated by Dr. Hyman: "Many people who get one diagnosis get five diagnoses, but they don't have five diseases -- they have one underlying condition."
Indeed, many of the experts who have lent their research to the DSM-5 readily admit that the manual does not classify mental illness based on the criteria of biology or neuroscience. As reported this week by Reuter's, one psychotherapist who performed field testing to help decide which illnesses should be included in the new DSM has said, of diagnosing mental disorders: "We don't have blood tests or other objective criteria to distinguish mental sickness from health. So you have a set of criteria that are very common, which means the potential for many people being diagnosed as mentally ill when they're not."
Still, plenty of doctors and mental health advocates maintain that the DSM is ultimately good for patients, and that the DSM-5's broader definition of many mental disorders means that more patients will receive the treatment they need. For example, the DSM-5 now lists compulsive gambling as an addition; thanks to this re-definition, people with a severe gambling problem should now have an easier time seeking counseling or other treatment. Importantly, with compulsive gambling listed in the DSM-5, insurance coverage for addiction therapy becomes easier to obtain.
Another good example of insurance benefits which may emerge from the DSM-5 is seen with the debate over a newly classified mental illness called Disruptive Mood Dysregulation Disorder. DSM-5 critics say that Disruptive Mood Dysregulation Disorder is a fancy name for temper tantrums - the disorder is found in children aged 6 to 18, and characterized by "temper outbursts that are grossly out of proportion in intensity or duration to the situation." However, some doctors are pleased to see tantrums described as a mental disorder - the new classification means that parents will have an easier time seeking behavior therapy for their children; therapy that must be covered by insurance plans that guarantee equal physical and mental health care coverage. In this way, classifying more diseases as mental health disorders can help more Americans to afford the cost of treatment.
The controversies surrounding mental illness research and the DSM-5 are intriguing, and sure to continue for years to come. A collection of symptoms does not make an illness - a cold and the flu may have common symptoms, but are different diseases requiring different treatments - yet at the same time, mental health care and insurance are an absolute necessity for a great many people. As research techniques and scientific technology improves, our understanding of mental illness will surely improve as well, and as our knowledge is expanded and amended, the DSM will no doubt grow as well.