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.