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Psychiatrist, heal thyself

The new psychiatric Bible’

3 minute read
Now the good news: Your insurance will cover your condition.
Now the good news: Your insurance will cover your condition.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorder has created a firestorm of debate and derision. DSM-5, which some call the psychiatric Bible, contains 157 entries, one of which is something called "Trichotillomania," also known as "hair-pulling disorder"— something that may well afflict its users.

You've heard it said— jokingly or not— that most psychiatrists go into the field in order to work out issues of their own. A slog through the manual's 991 pages suggests that the joke is no joke.

DSM-5 offers more psychiatric diagnoses than its predecessor, DSM-4, published 20 years ago. Many of the changes, says Dr. David Kupfer, chair of the DSM-5 task force, are adjustments made to better characterize disorder symptoms in terms of appearance, duration or severity.

But will DSM-5 be useful to practitioners and patients?

Do drugs help?

The main objection to DSM-5 is that it medicalizes some normal life events. Occasional sadness doesn't necessarily need to be classified as depression and treated with anti-depressants, a growing class of pharmaceuticals. The psychological therapist James Davies, in his new book, Cracked: Why Psychiatry is Doing More Harm Than Good, says that most of these medications don't provide any meaningful benefit.

According to the American Psychological Association, over-identifying or misidentifying people as being in need of treatment could lead to unnecessary and possibly harmful interventions. For instance, "Disruptive Mood Dysregulation" in children and adolescents lacks any solid research backing, and "Mild Neurocognitive Disorder" in the elderly might just have to do with nothing more alarming than expected cognitive decline and memory loss.

DSM-5 includes such non-pathologies as "Caffeine Withdrawal." In effect it makes all of us ripe for psychiatric medications covered by insurance. In fact, the manual is a guide to what insurers will or won't pay for. (All of the listed disorders are assigned code numbers, so that physicians can claim financial reimbursement for something that actually has a name.) Yet it offers some impossibly vague and confusing definitions, allowing drug companies to push dubious therapies.

Avoiding pain

Much of the interest in this taxonomy of real or imagined mental disorder is spurred by the widespread belief that you and I can lead a life free of anxiety or confusion or shyness. As the esteemed if eccentric Scottish psychiatrist R.D. Laing has quipped: "There is a great deal of pain in life, and perhaps the only pain that can be avoided is the pain that comes from trying to avoid pain."

A joint Anglo-American committee sponsored by the American Psychological Association questions the reliability and validity of many of DSM-5 diagnostic categories. The committee urges clinicians, researchers, journal editors, healthcare planners, the pharmaceutical industry, and the media to avoid using DSM-5 wherever possible and to sign a petition against it.

Does an expanding list of mental disorders mean we're getting battier? Probably not; but we might not be so sure about the American Psychiatric Association. That organization might do well to put itself on the couch… and vow to abide by that ancient medical dictum: "First, do no harm."

Or at least plan to add "DSM Disorder" to the next version of the manual.

What, When, Where

Diagnostic and Statistical Manual of Mental Disorder (Fifth Edition). American Psychiatric Association, 2013. 991 pages; $199. www.psychiatry.org/practice/dsm/dsm5.

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