The new DSM-5

By the book
The American Psychiatric Associations latest diagnostic manual remains a flawed attempt to categorise mental illness
May 18th 2013 | New York The Economist A BOOK with the tit e !"ia#nostic an$ %tatistica Man&a o' Menta "isor$ers( )i'th E$ition* $oes not so&n$ $estine$ to +e a +estse er( ,artic& ar y at -1.. a ,o,/ B&t "%M01( as it is known 'or short( is a most certain to +ecome one/ 2ts ,re$ecessor( "%M023( which was ,&+ ishe$ in 1..4( has so $ more than 1m co,ies/ "%M01( which wi #o on sa e on May 22n$( is ike y to $o at east as we / The reason is that the "%M series( which is ,&+ ishe$ +y the American 5sychiatric Association 6A5A7( has +ecome the # o+a stan$ar$ 'or the $escri,tion o' menta i ness/ 2n$ee$( the "%M is treate$ +y many ,eo, e ess as a me$ica han$+ook an$ more as ho y writ/ 2ns&rers &se it to $eci$e whether or not to co8er ai ments/ An$ $ia#noses +ase$ on it $etermine whether ,eo, e #et s,ecia ser8ices at schoo 9 whether they :&a i'y 'or $isa+i ity +ene'its9 whether they are sti#matise$ in their careers9 e8en whether they are a+ e to a$o,t chi $ren/ "octors( ,atients( $r&# com,anies an$ ins&rers ha8e a th&s +een waitin# 'or the atest e$ition o' what has +ecome known as the ,sychiatric +i+ e/ The "%M;s ,&r,ose is to set strict criteria 'or i$enti'yin# menta $isor$ers/ This is s&,,ose$ to make $ia#noses more re ia+ e< a a&$a+ e aim/ To that en$( more than 1(100 e=,erts ha8e s,ent o8er a $eca$e a+o&rin#/ 2n $oin# so( tho&#h( they ha8e s&ccee$e$ in a$$in# to( rather than s&+tractin# 'rom( criticism that the "%M has +ecome a monster/ 2n the eyes o' many critics it is a 8ehic e 'or mis$ia#nosis( o8er$ia#nosis( the me$ica isation o' norma +eha8io&r an$ the ,rescri,tion o' a ar#e n&m+er o' &nnecessary $r&#s/ Chapter and verse The "%M( the 'irst 8ersion o' which was ,&+ ishe$ in 1.12( has a ways attracte$ contro8ersy/ That 8ersion( an$ the secon$ e$ition( ,&+ ishe$ in 1.>8( re ie$ on the ,remise that menta i ness was a ne&rotic res,onse to a ,atient;s e=,erience an$ en8ironment/ 5eo, e with the same sym,toms co& $ there'ore recei8e wi $ y $i''erent $ia#noses/ "i''erent inter,retations o' e=,erience an$ en8ironment a so meant that c& t&ra $i''erences a''ecte$ $ia#nosis/ 2n 1.?1 @o+ert Ken$e $emonstrate$ this +y showin# that( 'ace$ with the same ,atients( American ,sychiatrists were m&ch more ike y to $ia#nose them as schiAo,hrenic than were British ,sychiatrists/ The thir$ "%M( ,&+ ishe$ in 1.80( intro$&ce$ a new a,,roachBa so 'o owe$ in the 'o&rth in 1..4/ "%M0222 acknow e$#e$ that ,sychiatrists ha$ a ,oor &n$erstan$in# o' the ,hysio o#ica ca&se o' menta i ness/ 2nstea$ s,eci'ic( o+ser8e$ sym,toms +ecame the $ia#nostic criteria( an$ c &sters o' them( known me$ica y as syn$romes( that a,,eare$ to coe=ist in in$i8i$&a ,atients were #i8en a+e s/ The ho,e was that +io o#ica markers o' s&ch syn$romes wo& $ +e $isco8ere$ as ,hysio o#ica &n$erstan$in# increase$/ This was a reasona+ e a,,roach in ,rinci, e/ 2n ,ractice( tho&#h( the ines $i8i$in# $i''erent $isor$ers are + &rry/ The sym,toms &se$ to $e'ine them o'ten $o not c &ster neat y in the way that those o' tr&e syn$romes wo& $( an$ the statistica

e8i$ence 'or their e=istence is sometimes s,arse/ Nor( in most cases( ha8e the ho,e$0'or +io o#ica markers t&rne$ &,Ban$ to the e=tent that they ha8e( they ha8e m&$$ie$ the waters( rather than c ari'yin# them/ The +i##est m&$$yin#s ha8e come 'rom +rain scannin# an$ #enetics/ Most ,sychiatrists( e8en those sce,tica o' the "%M;s a,,roach( wo& $ acce,t the i$ea that thin#s ike a&tism( maCor $e,ression an$ schiAo,hrenia are $i''erent 'rom each other/ Dowe8er( a st&$y ,&+ ishe$ this year +y a #ro&, ca e$ the 5sychiatric Eenomics Fonsorti&m( which has ooke$ 'or inks +etween #enetic 8ariations an$ ,sychiatric $isor$ers in tens o' tho&san$s o' ,atients( has 'o&n$ that 8ariations in 'o&r , aces were common to ,eo, e $ia#nose$( &sin# the "%M;s criteria( with attention $e'icit hy,eracti8ity $isor$er 6A"D"7( a&tism( +i,o ar $isor$er( maCor $e,ression an$ schiAo,hrenia/ Gikewise( a series o' ,a,ers o8er the ,ast $eca$e ha8e shown simi ar a+norma acti8ation o' ,art o' the +rain ca e$ the amy#$a a in ,eo, e $ia#nose$ with an=iety( maCor $e,ression an$ ,ost0tra&matic stress $isor$er/ %&ch res& ts s&##est that the "%M;s a,,roach o' , acin# ,atients in $ia#nostic si os is :&estiona+ e/ As "an B aAer o' "&ke Hni8ersity( who ser8e$ on "%M01;s task0'orce( ,&ts it( !Ie;re +asica y $rawin# arti'icia ines( an$ the +o$y an$ the min$ $o not work ike that/* The new "%M as,ires to inc &$e o+Cecti8e criteria in its man&a / 2t a so seeks to scra, nonsensica ( strict ines +etween certain $isor$ers/ t has! for e"ample! chun#ed together four previously separate diagnoses! including autism and Aspergers syndrome! into one disorder of varying severity! #nown as $autism spectrum disorder%& n this! it is following clinical practice! for the idea of an autistic spectrum has 'een around for a long time& And the unfortunate truth is that it is still far too early to use 'iological mar#ers as criteria for diagnosis& !The h&man +rain is the most im,ossi+ y com, e= thin# in the &ni8erse(* says A en )rances( who e$ the $e8e o,ment o' "%M023/ !2t $oes not yie $ its secrets easi y/* Iorse( ar#&es "r )rances( "%M01 has not sto,,e$ the rise in the n&m+er o' a e#e$ y reco#nisa+ e an$ namea+ e menta con$itions( many o' which anne= into ,sychiatry thin#s that the man in the street wo& $ think norma ( i' not a ways $esira+ e( +eha8io&r/ Fhi $ren may now( 'or e=am, e( +e $ia#nose$ with !$isr&,ti8e moo$ $ysre#& ation $isor$er*Bwhat &se$ to +e known as tem,er tantr&ms/ 5ast 8ersions o' the "%M sti,& ate$ that those mo&rnin# a $eath sho& $ not +e c assi'ie$ as $e,resse$/ "%M01 scra,s this !+erea8ement e=c &sion*/ 2t a so inc &$es a new +in#e0eatin# $isor$er( $e'ine$ as eatin# to e=cess at east once a week o8er the ,re8io&s three months/ %&ch a $ia#nosis co8ers mi ions o' Americans( ro,in# in ,eo, e who wo& $ not remote y consi$er that they were menta y i / "%M01 $oes not( a'ter some $e+ate amon# those who ,&t it to#ether( make a$$iction to internet #amin# a 'orma $isor$er/ B&t it recommen$s '&rther research into the !con$ition*/ Erie'/ 2n$& #ence/ Hnhea thy ha+its/ A ( it seems( may +e c assi'ie$ as menta $eran#ement( an$ treate$ as s&ch/ An$ the sets o' sym,toms $escri+e$ +y the "%M are o'ten common/ More than one American chi $ in ten has +een $ia#nose$( &sin# the "%M;s $e'inition( with A"D"Ban$ a+o&t two0thir$s o' those so $ia#nose$ are now ,rescri+e$ $r&#s/ 2t is this o8er$ia#nosis an$ o8ertreatment that is the chie' criticism o' the "%MB or( rather( o' the ,ower it wie $s in the ,ro'ession o' ,sychiatry/ That ,ower( howe8er( may +e wanin#/

(iterary criticism "%M cate#ories ha8e on# +een &se$ in research/ That is chan#in#/ Other areas o' me$icine( cancer in ,artic& ar( ha8e +een trans'orme$ +y +etter &n$erstan$in# o' the +io o#ica $ri8ers o' $isease/ America;s Nationa 2nstit&te o' Menta Dea th 6N2MD7 ho,es that wi trans'orm ,sychiatry( too/ The N2MD seeks to &se #enetics( ima#in# an$ co#niti8e science to create new $ia#nostic criteria/ Thomas 2nse ( the N2MD;s $irector( has s,eci'ica y im, ore$ researchers not to +e con'ine$ +y "%M0 1;s strict r& es/ A+i$in# +y "%M cate#ories may ,re8ent scientists 'rom &n$erstan$in# the &n$er yin# ca&ses o' sickness/ %ti ( o+Cecti8e a+oratory meas&res 'or menta i ness are a on# way o''/ The A5A says "%M01 wi +e contin&o&s y &,$ate$ to res,on$ to new $isco8eries/ )or now( howe8er( ,atients; treatment wi +e #&i$e$ +y the im,er'ect man&a / !The "%M is ,&re y a ,ro$&ct o' the state o' o&r know e$#e at this ,oint in time(* says Je''rey Gie+erman( the chairman o' Fo &m+ia Hni8ersity;s ,sychiatry $e,artment an$ ,resi$ent0e ect o' the A5A/ !The state o' o&r know e$#e is not com, ete/*

The

DSM-5

Attention,

everyone
May 22n$ 2013( The Economist A)TE@ near y two $eca$es( the new "%M has arri8e$/ The "ia#nostic an$ %tatistica Man&a o' Menta "isor$ers is a .4?0,a#e #&i$e to ai ments o' the min$/ 5&+ ishe$ on May 22n$ +y the American 5sychiatric Association 6A5A7( it ists s,eci'ic sym,toms to +e attri+&te$ to this $isor$er or that/ The "%M is h&#e y in' &entia / 2ts cate#ories #&i$e research an$ treatment 'or mi ions o' ,atients in America an$ e sewhere/ Fr&cia y( it a so ,ro,e s the ,sychiatry in$&stryBi' a $isor$er is inc &$e$ in the "%M( ins&rers are more ike y to ,ay 'or it/ Anythin# so im,ortant is ri,e 'or contro8ersy/ This "%M( in ,artic& ar( has ins,ire$ 'its/ Fritics 6inc &$in#( to a $e#ree( this news,a,er7 yow that the "%M wi ea$ to o8er0$ia#nosis that +ene'its ,sychiatrists an$ $r&# com,anies/ The "%M;s a&thors co&nter that the #&i$e re' ects the '& e=tent o' c&rrent know e$#e( which they a$mit is im,er'ect/ )&rthermore( the "%M is an essentia too to i$enti'y ,atients in nee$ o' he ,/ At the A5A;s ann&a meetin# in %an )rancisco on May 18th( the #ro&,;s ea$ers #athere$ re,orters in a s&+0s&+0+asement to to&t e=citin# chan#es to the "%M/ The man&a has new too s to he , ,atients an$ ,sychiatrists with assessment( yo&r corres,on$ent an$ the others were to $/ Fha,ters are reor#anise$ to re' ect new &n$erstan$in# in #enetics an$ ne&roima#in#/ B&t the more ,rominent $e+ate was at street e8e ( where the ,o ar e=tremes o' the 'i#ht were on $is, ay/ On one si$e o' the street were %ciento o#ists ho $in# si#ns with 8ario&s s o#ans( inc &$in# !Fhi $hoo$ is not a menta $isor$er*/ On the other si$e were +&ses( there to take atten$ees to an$ 'rom the meetin#( em+ aAone$ with a$8ertisements 'or Eenentech( a ,harmace&tica com,any/ Ihy is the contro8ersy so im,ortantK E e8en ,ercent o' American schoo 0a#e chi $ren ha8e +een $ia#nose$ with attention0$e'icitLhy,eracti8ity $isor$er 6A"D"7/ Astonishin# y( one in 'i8e +oys a#e$ 1401? ha8e +een th&s c assi'ie$/ Amon# those c&rrent y a+e e$ as ha8in# A"D"( two0thir$s are on ,rescri,tion $r&#s/ The "%M is ike y to ea$ to e8en more A"D" $ia#noses( ,artic& ar y 'or teena#ers an$ a$& ts/ The ,rior "%M( ,&+ ishe$ in 1..4( re:&ire$ sym,toms to +e ,resent +e'ore the a#e o' se8en/ The new 8ersion raises that to 12/ A$& ts no on#er ha8e to ,resent si= sym,toms to +e $ia#nose$/ The new thresho $ is 'i8e/ This wi ha8e a +i# im,act on $r&# sa es/ On May 21st E=,ress %cri,ts( a ,harmacy0+ene'it mana#er( ,&+ ishe$ its ann&a re,ort on American $r&# tren$s/ The com,any e=,ects +roa$ $r&# s,en$in# 'or common ai ments( s&ch as asthma an$ hy,ertension( to 'a +y 4M o8er the ne=t three years/ Dowe8er( sa es o' attention0$isor$er $r&#s wi C&m, +y 21M o8er the same ,erio$/ The s,ike is $&e not to the arri8a o' e=,ensi8e new treatment( +&t to a s,ike in ,rescri,tions amon# a$& ts/ The &se o' attention $r&#s is hi#hest in AmericaNs so&th/ This &n$erscores somethin# most ,sychiatrists know we / Neither a rise in $r&# sa es nor #eo#ra,hic 8ariation can +e e=, aine$ ,&re y +y ,re8a ence o' a menta $isor$er/ @ather( these shi'ts re' ect chan#es in $ia#nostic ,ractice/ %ome o' the new y $ia#nose$ ,atients may ha8e +een &nC&st y ne# ecte$ to $ate/ Many wi +e

the res& t o' more re a=e$ $ia#nostic r& es/ This is ,ro+ ematic( not east +eca&se the o8er0treatment o' some menta $isor$ers coinci$es with the &n$er0treatment o' others/ 5&+ ic ser8ices 'or the menta y i $ec ine$ $&rin# the recession/ 2nstea$ o' recei8in# ,ro,er treatment( many en$ &, in ,rison/ More than ha ' o' America;s ,rison ,o,& ation has some kin$ o' menta i ness/

Psychiatry
A single 'oo# has come to dominate psychiatry& That is dangerous May 18th 2013 | The Economist
TDE h&man +rain is the most com, e= o+Cect in the known &ni8erse/ 2t contains 100 +i ion ner8e ce s/ Fonsi$erin# how com, e= that is( it #oes wron# remarka+ y rare y/ B&t #o wron# it sometimes $oes/ Ihich is why( since 1.12( the American 5sychiatric Association has ,&+ ishe$ its !"ia#nostic an$ %tatistica Man&a o' Menta "isor$ers*( the "%M/ This +ook( the newest 8ersion o' which wi hit the sho,s on May 22n$ 6see artic e7( contains the association;s thinkin# on what constit&tes a $isor$er o' the min$/ 2t is cons& te$ not on y +y ,sychiatrists( +&t a so +y ins&rance 'irms( $r&# com,anies an$ an=io&s ,atients an$ ,arentsBnot on y in America( +&t aro&n$ the wor $/ 2t has +ecome the in$&stry stan$ar$ 'or $e'inin# what is an$ is not a menta i ness( an$ th&s who #ets treate$( an$ who ,ays 'or treatment/ No other maCor +ranch o' me$icine has s&ch a sin# e te=t( with so m&ch ,ower o8er ,eo, e;s i8es/ An$ that is worryin#/ Beca&se in no other +ranch o' me$icine is the scienti'ic rea ity &n$er,innin# the ,rono&ncements o' $octors so &ncertain/ The categorical imperative This &ncertainty ' ows 'rom a ,ro'o&n$ i#norance a+o&t how +rains act&a y work/ Ne&roscientists &n$erstan$ how ner8e ce s work/ They a so know which +its o' the +rain $ea with 8ision( ocomotion( an#&a#e( memory an$ s&ch ike/ B&t +etween these two anatomica e8e s a is $arkness/ 5sychiatrists ha8e th&s ha$ to &se +eha8io&r ,atterns as ,ro=ies 'or &n$er yin# ,ro+ ems/ An$ what constit&tes a ,attern is too o'ten a matter o' o,inion rather than a statistica y ri#oro&s 'act/ 2t is this $esire to 'in$ an$ c assi'y ,atterns which #i8es the "%M its ,ower/ By namin# thin#s it #i8es sha,e to the ' e$# in# science/ That is not a +a$ thin# in ,rinci, e/ B&t in ,ractice it has #one too 'ar/ The main criticisms are that it me$ica ises norma +eha8io&r an$ that the strict cate#ories o' menta i ness it creates are increasin# y at o$$s with what research s&##ests is act&a y #oin# on in the +rain/ Both criticisms are & timate y a+o&t names/ The "%M #i8es names ike !$isr&,ti8e moo$ $ysre#& ation $isor$er* to tem,er tantr&ms in chi $ren an$ !+in#e eatin# $isor$er* to those who ten$ to o8ereat/ 2' these were mere a+e s( ,erha,s it wo& $ not matter 6tho&#h in the area o' menta hea th e8en a a+e can +e $amnin#7/ B&t $ia#nosis 're:&ent y ea$s to ,rescri,tion( an$ ots o' ,i s are th&s +ein# ,o,,e$ +y ,eo, e whose nee$ to take them is( to say the east( :&estiona+ e/ The way the "%M c assi'ies those who &n:&estiona+ y are i is a so &n$er attack/ %chiAo,hrenia( maCor $e,ression an$ some 'orms o' a&tism are $isa+ in# con$itions that ha8e on# +een consi$ere$ se,arate $iseases/ B&t mo$ern techni:&es o' #ene ana ysis an$ +rain scannin# are ea$in# some researchers to won$er whether they rea y can +e $istin#&ishe$ in the way that( say( 8ario&s 'orms o' e&kaemia can +e $i''erentiate$B'or their +io o#ica &n$er,innin#s seem to o8er a,/ Iitho&t a ,ro,er $ia#nosis( ,ro,er treatment is har$/ 3eneration o' the "%M is a so harm'& in research/ Thomas 2nse ( the hea$ o'

America;s Nationa 2nstit&te o' Menta Dea th( has ,&+ ic y enco&ra#e$ scientists not to +e constraine$ +y its a,,roach( est it ,re8ent them 'in$in# $ia#noses an$ treatments/ 2n terms o' $ia#nosis( a 'ew ,sychiatrists 6inc &$in# those who con$&cte$ the #enetics an$ +rain0scannin# st&$ies7 now ,&+ ic y ,oint to the "%M;s $e'iciencies9 yet the "%M;s $e'initions an$ certainties are too $ee, y in#raine$ 'or this criticism to ha8e hit home/ The '& conse:&ences o' that wi not +e o+8io&s 'or a on# time/ B&t the c&rrent o8er0re iance on one ,oint o' 8iew in this e=treme y &ncertain science is hea thy neither 'or ,sychiatry( nor 'or those it treats/