Image: Illustration by Patrick George
In Brief
Fast Facts: A New Guide to Your Psyche
- The fifth version of psychiatry’s bible, the Diagnostic and Statistical Manual of Mental Disorders, slated for publication in May 2013, represents the first substantial change to psychiatric diagnosis in more than 30 years.
- In 2010 the American Psychiatric Association debuted a draft of the new manual on their Web site that has so far received 50 million hits from about 500,000 individuals, many of them critics.
- The revised manual will very likely scrap psychiatry staples such as Asperger’s syndrome and paranoid personality disorder.
- Additions to the diagnostic menu are likely to include an ailment for children marked by severe temper tantrums and for adults a type of sex addiction.
Editor's Note: Read our blog series on psychiatry's new rulebook, the DSM-5.
In February 1969 David L. Rosenhan showed up in the admissions office of a psychiatric hospital in Pennsylvania. He complained of unfamiliar voices inside his head that repeated the words “empty,” “thud” and “hollow.” Otherwise, Rosenhan had nothing unusual to report. He was immediately admitted to the hospital with a diagnosis of schizophrenia.
Between 1969 and 1972 seven friends and students of Rosenhan, a psychology professor then at Swarthmore College, ended up in 11 other U.S. hospitals after claiming that they, too, heard voices—their sole complaint. Psychiatrists slapped them all with a diagnosis of schizophrenia or bipolar disorder and stuck them in psychiatric wards for between eight and 52 days. Doctors forced them to accept antipsychotic medication—2,100 pills in all, the vast majority of which they pocketed or tucked into their cheeks. Although the voices vanished once Rosenhan and the others entered the hospitals, no one realized that these individuals were healthy—and had been from the start. The voices had been a ruse.
The eight pseudopatients became the subject of a landmark 1973 paper in Science, “On Being Sane in Insane Places.” The conclusion: psychiatrists did not have a valid way to diagnose mental illness.
Rosenhan’s experiment motivated a radical transformation of the essential reference guide for psychiatrists: the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA). The revamped DSM, dubbed DSM-III and published in 1980, paired every ailment with a checklist of symptoms, several of which were required for a diagnosis to meet the book’s standards. Earlier versions of the DSM contained descriptive paragraphs that psychiatrists could interpret more loosely. This fundamental revision survives today.
The APA is now working on the fifth version of the hefty tome, slated for publication in May 2013. Because the DSM-IV was largely similar to its predecessor, the DSM-5 embodies the first substantial change to psychiatric diagnosis in more than 30 years. It introduces guidelines for rating the severity of symptoms that are expected to make diagnoses more precise and to provide a new way to track improvement. The DSM framers are also scrapping certain disorders entirely, such as Asperger’s syndrome, and adding brand-new ones, including binge eating and addiction to gambling.
In the past the APA has received harsh criticism for not making its revision process transparent. In 2010 the association debuted a draft of the new manual on its Web site for public comment. “That’s never been done before,” says psychiatrist Darrel Regier, vice chair of the DSM-5 Task Force and formerly at the National Institute of Mental Health. The volume of the response surprised even the framers: 50 million hits from about 500,000 individuals and more than 10,000 comments so far.
Critics swarmed the drafts. Some psychiatrists contend that the volume still contains more disorders than actually exist, encouraging superfluous diagnoses—particularly in children. Others worry that the stricter, more precise diagnostic criteria may inadvertently give insurance companies new ways to deny medication to patients who need it.
The debates surrounding the manual’s revisions are not merely back-office chatter. Although many psychiatrists do not sit down with the DSM and take its scripture literally—relying instead on personal expertise to make a diagnosis—the DSM largely determines the type of diagnoses clinicians make. Insurance companies often demand an official DSM diagnosis before they pay for medication and therapy. Many state educational and social services—such as after-school programs for kids with autism—also require a DSM diagnosis. Consequently, psychiatrists cannot dole out diagnoses of their own invention. They are bound to the disorders defined by the DSM.
Rights & Permissions
See what we're tweeting about
22 Comments
Add Comment"Although many psychiatrists do not sit down with the DSM and take its scripture literally..."
Reply | Report Abuse | Link to thisThis is an important caveat. And it illustrates why more attention needs to be drawn not to what's in the book, but how the book is used.
As a practicing psychiatrist, I agree with you that many clinicians "rely on personal expertise to make a diagnosis." What we are forced to write in the chart, however, is dictated by the DSM. From that point on, the diagnosis-- NOT the patient-- becomes the focus of treatment. It serves as a gateway not only to a wide range of social services-- which could be beneficial-- but also to a potential lifetime of medication trials and other ill-advised treatments.
Most psychiatrists view the DSM and the diagnostic process as a necessary evil: "necessary" for reimbursement and to be able to help the people who seek our assistance, but "evil" because in many systems the assistance we provide is dictated by the diagnosis, not by the unique needs of the individual.
"Residual: very few typical symptoms but some odd beliefs or unusual sensory experiences."
Reply | Report Abuse | Link to thisThat describes most of the people I know.
The DSM is nothing more than a piece of trash. These so called conditions were made up from a committee of "scientists" the majority of whom have financial connections to drug companies. These companies are drooling over the fact that new markets will be open to them to sell more worthless and harmful drugs. There is absolutely NO scientific basis for the conditions included in the DSM. This is nothing more than a sham to make insurance companies pay for more drug therapy at an astronomical increase in cost.
Reply | Report Abuse | Link to thisQuote: In the past the APA has received harsh criticism
Reply | Report Abuse | Link to thisAnswer: "I have lived a full, interesting and creative life supported by my family and many friends and irritated and spurred on by the hostile criticisms of a group of psychiatrists representing APA and NIMH."
Those words were spoken by Dr. Abram Hoffer , 'father of Orthomolecular Psychiatry'.
http://orthomolecular.org/history/hoffer/index.shtml
"Catatonic schizophrenic"
"Left in a coma and was dying"
"The next day he sat up and drank it and thirty days later he was well. He was discharged and remained well"
The American Psychiatric Association advocates AGAINST the use of the treatment above.
The American Psychiatric Association MUST be harnessed and their powers removed.
So, ironjustice, all you have is a story from the website of orthomolecular.org itself?
Reply | Report Abuse | Link to thisEven if it's true, it occasionally happens that people wake up from a coma for no discernible reason. One case is not statistically significant.
"Schizophrenia is characterized by a tenuous grasp of reality, difficulty thinking and speaking clearly, and unusual emotional responses."
Reply | Report Abuse | Link to thisCan we use this diagnosis for political parties? Pretty please with sugar on top?
But seriously. Opening the process is probably a good thing. But does it go far enough? AFAIK, the DSM was originally a collection of random wisdom from a bunch of doctors. It was unexpectedly a best seller. Arguably, it's long past time to put some science into it. One hears phrases like "evidence based medicine". How would that work with the DSM? Maybe pilot projects. One publishes a DSM for Wayne County, and another for Macomb County. Figure out the pluses and minuses of each through use, and apply the results to the next pilot projects. Results are only expanded to larger populations when the desired outcomes are maximized. No politics. No vested interests. This isn't easy, but it appears that there is a mandate.
If religion had to undergo as massive and dramatic an overhaul as this, devotees of "science" would roundly denounce it. In fact, "psychiatry", "psychology", "psychoanalysis" all have traits that utterly disqualify them much less than as "scientific", but even as useful. Consider that all "psychoanalytic theories" are definitively different, if not wholly incompatible. Freud's emphasis on sex, Fromm saying a desire for conformity and programming defines man, Skinner saying everything is already programmed, Jung invoking already defined stereotypes. And all supposedly describing the same human mand! And yet no devotees of "science" attack "psychology" as a fraud! They respect the money, not ethics! Just as in the case of the single most accusatory quality of "psychoanalysis". Claiming to be a modeling of all human minds, "psychoanalytic theories" all derive solely from case histories! All "psychoanalytic theory" is based on individuals with proven mental instabilities, yet, they try to generalize from these to healthy minds! No "psychoanalytic theory" recognized by "science" derived from interviewing sane people!
Reply | Report Abuse | Link to thisDave , there is no room to place much of his 600 published works. The fact you seem not to know anything OTHER than that which I have placed , one article , means ? You don't have the gear to be commenting.
Reply | Report Abuse | Link to thisWhat evidence do you have of this alleged interference from drug companies? That's a strong accusation to make blindly.
Reply | Report Abuse | Link to thisI've often thought it's very ironic that "science-based" critics of alternative medicine ignore therapists and psychologists, who *really* have little or no research support for much of what they do. Psychiatrists might practice somewhat more science-based medicine, but still deserve criticism from a science-based point of view.
Reply | Report Abuse | Link to thisQuote: what evidence
Reply | Report Abuse | Link to thisAnswer: Depakote.
600? So? L. Ron Hubbard published far more.
Reply | Report Abuse | Link to thisQuite the generalization, that is.
Reply | Report Abuse | Link to thisQuote: L. Ron Hubbard published far more
Reply | Report Abuse | Link to thisAnswer: Typed that name into Medline. No hits.
A good companion to the DSM is the "Psychodynamic Diagnostic Manual". This book informs us about the patient rather than the diagnosis. It is linked to the DSM classification of disorders and so provides us with an informative complement to the DSM.
Reply | Report Abuse | Link to thisThe DSM5 comment process as diagnostic tool - fifty million comments, mostly critical, from half a million individuals. Average 100 comments per individual. I'd guess most sane individuals probably commented 1, 2 or 10 issues. I hope they gave no weight to the comments of those who submitted hundreds or thousands.
Reply | Report Abuse | Link to thisIt's "Psychology's," not "Psychiatry's." Psychiatrists mainly dispense meds. In fact, psychiatrists are required to have no psychological training. Psychologists use the DSM a whole order of magnitude more than psychiatrists. I'd expect SciAm to get that right.
Reply | Report Abuse | Link to this-Dr.Bunny
As someone who has worked in this field for 40 years and been psychoanalyzed, trained first as a Rogerian, then a psychoanalytic, then Eriksonian and lastly CBT therapist; worked in an acute inpatient setting, a multidisciplinary outpatient setting, for a managed care insurance company, doing admissions for an facility and currently working in an outpatient practice group I can say that the DSM is an important tool. It does not capture the unique individual in the room but it provides a framework for organizing ones thinking about that person.
Reply | Report Abuse | Link to this"Suspiciously, between 40 and 60 percent of all psychiatric patients are diagnosed with a personality disorder, hinting that symptoms of at least some of these “disorders” resemble typical behavior too closely."
Reply | Report Abuse | Link to thisI think that often a doctor will add on a personality disorder because the diagnosed clinical disorder does not contain all the patient's relevant symptoms.
--
I'm glad concepts like severity and behavior spectrums are starting to be introduced.
There is a catch 22 especially with anti psychotic medications. After you have been on them for months and seek to withdraw from the medication the withdrawal side effects are exactly the behaviors that supposedly were diagnosed in the first place and then some. Anti psychotic drugs cause an even greater chemical imbalance in the brain than actually existed at the time of the diagnosis and treatment. Withdrawal from anti psychotic drugs makes you even crazier than when you first started out with the medication.
Reply | Report Abuse | Link to this"What evidence do you have of this alleged interference from drug companies?" Is that Musclefox of fox tv.? All aspects of US society are controlled by Corporations. The FDA and Dept of Ag. are run by Monsanto, Condoleezza Rice went from Exon to Secretary of State for Bush/Chaney's OIL WAR Industry, The Dept. of Energy historically by Coal ,Oil and Nuclear Industries Retirees ,The Senate Watch dog on Internet Porn gets busted with young boy in public restroom, What Govt. agency is not run by 'the fox guarding the Hen house'. Corporations Make the rules Americans have to live by. The People have no voice, not in the White House,Congress, or the Corporate Media, Against them.The Pharmaceutical Companies keep America the Most Doped Up people in the World. What evidence do you need ? If you will not believe FACTS ! But You won't hear that on Fox news.Occupy Truth ! Freud was a Fraud which Drug Companies Perpetuate through Funding of 'University Studies' .
Reply | Report Abuse | Link to thisSeveral stupid police officers in Western Australia just recently abducted some innocent guy off the street in Perth, and handed him over to psychiatric staff from Graylands Hospital, who then promptly injected him with a powerful drug to sedate him, ignoring his protests all the while. This innocent guy had an immediate adverse reaction to the drug and had to be hospitalised at a major hospital. It turns out that this poor fellow was mistaken for a psychiatric patient who'd absconded from Graylands where he'd been in psychiatric care for approximately eight months, yet the extremely "lax"[read as: stupid] psychiatric staff were unable to positively identify the patient being sought and thought that this guy will do since he's being given them by the police. He was securely handcuffed after possibly being roughed-up by the police to boot. This just shows how inadequately putatively trained psychiatric staff keep their patients under observation and typifies how they're also unable to assess the mental condition of any person adequately, just like the myriad psychiatrists involved with the fiasco that occured during the "Rosenhan Pseudopatient Experiment" in the United States of America. The Graylands patient who was still being sought presented himself back at the secure ward several days later, entirely of his own volition.
Reply | Report Abuse | Link to thisUntil such time that we are provided with something far superior than just the fallible human brain with which to assess any person's mental condition, present-day psychiatric assessments are about as futile as the endeavour of an inept businessman who doesn't advertise. This inept businessman, because he doesn't advertise his business, is just like the guy who winks at a pretty girl in the dark. He knows what he's thinking...but nobody else does! Maybe he could do better working as a psychiatrist?