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In May of 2013 the American Psychiatric Association will release its fifth edition of its Diagnostic and Statistical Manual of the Mental Disorders, the DSM-5, replacing the current DSM-IV, right down to its Roman numerals. The Diagnostic and Statistical Manual provides a common language and a standard for diagnosing psychiatric disorders that is used by members of the American Psychiatric Association, US insurance companies, pharmaceutical manufacturers of drugs used in the United States, other mental health professionals in the United States, and to a lesser extent by their counterparts throughout the world.
Psychiatry, of course, is big business. The inclusion or exclusion of symptoms for the diagnosis of a mental health condition, or the inclusion or exclusion of the mental health condition itself, have enormous implications. Drug companies can earn or lose tens or even hundreds of millions of dollars on the basis of the DSM, and patients can gain or lose insurance coverage when changes are made to the DSM.
Critics of the recent editions of the DSM have numerous complaints. Among objections to this Diagnostic and Statistical Manual these surface again and again:
- The diagnostic criteria codified in the DSM are based on superficial behaviors.
- The distinctions between illness and normality are artificial.
- There is obvious cultural bias in the DSM, that is, it has been written from an American, white, male perspective (and undoubtedly the first three editions of the DSM were).
- Trivial mental health disorders are included and imported mental health disorders are left out.
In light of recent events in the US, the inclusion or exclusion of certain mental health disorders will become very controversial next year, as will be explained later in this article.
How Do Mental Health Professionals Use the DSM?
If you were to glance through any edition of the DSM, you would see a collection of checklists. Each checklist presents a series of symptoms. A patient might have to display some or all of the elements in a checklist to be diagnosed with the condition.
For example, a person displaying "odd" but not "dramatic" behavior might be diagnosed with a paranoid personality disorder if he or she displays a pervasive distrust of others and four or more of the following seven characteristics:
1. Unjustified belief that others are harming or exploiting him or her.
2. Preoccupation with the trustworthiness of friends or associates.
3. Reluctance to confide in others due to fear information will be used malevolently.
4. Reading hidden, threatening meanings into innocuous remarks.
5. Bearing grudges.
6. Reacting to slights or hurts not perceived by others.
7. Recurrent, unjustified, doubts or fears about spouse or sexual partner.
Four or more of these symptoms justifies, but does not require, a diagnosis of paranoid personality disorder. If a person displays just three of these symptoms, a psychiatrist may still offer treatment, but there would likely not be a diagnosis of paranoid personality disorder.
Professional judgment is still key
The American Psychiatric Association, as you might expect explicitly states that the DSM is not be used in a "cookbook" fashion. The DSM is not intended to replace professional judgment. It is a "shorthand" for psychiatrists and other mental health professionals. Changing the shorthand, however, can lead to tremendous controversy outside the psychiatric profession.