The coming months will see the release of the D.S.M – 5. This 5th edition of the diagnostic and statistical manual is getting lots of news. Originally a useful tool for mental health professionals, allowing us to agree on who may or may not warrant a particular diagnosis, the manual has been co-opted and hijacked by many others for a variety of less noble purposes. We have attached two of many articles appearing in recent months. More will certainly come.
The hazards and dangers of the D.S.M are many. A main theme includes the medicalization and pathologizing of normal life. Grieve a loved one: Bereavement disorder. A bit strange? Autistic Spectrum Disorder; Crave Food or Alcohol: Addiction disorder; Easily Distracted: Attention Deficit Disorder. The list goes on. To the degree labels help treat problems they can be useful. To the degree that they confer entitlements, exculpation of responsibility, mandated health benefits, employment accommodation, legal responsibility or lack of responsibility – the benefits are far less clear and capacity for mischief and abuse quite evident.
The following cautionary statement appears in the preface of the D.S.M. – 4: (emphasis added)
The specified diagnostic criteria for each mental disorder are offered as guidelines for making diagnoses, because it has been demonstrated that the use of such criteria enhances agreement among clinicians and investigators. The proper use of these criteria requires specialized clinical training that provides both a body of knowledge and clinical skills.
These diagnostic criteria and the DSM-IV Classification of mental disorders reflect a consensus of current formulations of evolving knowledge in our field. They do not encompass, however, all the conditions for which people may be treated or that may be appropriate topics for research efforts.
The purpose of DSM-IV is to provide clear descriptions of diagnostic categories in order to enable clinicians and investigators to diagnose, communicate about, study, and treat people with various mental disorders. It is to be understood that inclusion here, for clinical and research purposes, of a diagnostic category such as Pathological Gambling or does not imply that the condition meets legal or other non-medical criteria for what constitutes mental disease, mental disorder, or mental disability. The clinical and scientific considerations involved in categorization of these conditions as mental disorders may not be wholly relevant to legal judgments, for example, that take into account such issues as individual responsibility, determination, and competency.
Hopefully this statement or similar variant will remain in the upcoming edition. We should add: “Insurance coverage, employment and school accommodation, and denial or impact of individual choice or responsibility.
Psychiatry is not the only specialty guilty of misrepresenting science for politics, social justice and economic self-interest. But I fear we may be about to outperform in this capacity to the degree we use diagnoses to define not true disease, but normal human experience and variations. And to the degree others coattail on these diagnoses for goals other than improving emotional and mental states.