“Revising Book on Disorders of the Mind” http://www.nytimes.com/2010/02/10/health/10psych.html?em is a NY Times article by Benedict Carey, printed February 10, 2010 and Shari Roan in the LA Times, http://www.latimes.com/news/nationworld/nation/la-sci-dsm10-2010feb10,0,2650262.story, remind us that psychiatrists, to quote Mr. Carey, are creating a new line between ”normal and not normal, between eccentricity and illness, between self-indulgence and self-destruction-and, by extension, when and how patients should be treated.”
In my previous blogs, I have discussed the floating away of the term Asperger’s Disorder http://shirahvollmermd.wordpress.com/category/musings/dsm-v/ and the arbitrariness of our diagnostic system. http://shirahvollmermd.wordpress.com/category/musings/dsm-v/. I have also discussed the diagnosis of gender identity disorders, and how this label should change http://shirahvollmermd.wordpress.com/2010/01/23/gender-identity-disorders-in-girls-a-plea-for-a-label-change/ and .http://shirahvollmermd.wordpress.com/2010/01/23/boy-or-girl-introducing-a-continuum/.
One interesting change is that DSM is moving from Roman numerals to Arabic numerals, presumably because the authors are anticipating minor changes in the future, so there will be DSM 5.1 and then DSM 5.2. http://www.latimes.com/news/nationworld/nation/la-sci-dsmbox10-2010feb10,0,7852958.storyI admit to my skepticism that part of the DSM world involves the money made from publishing the manual, so the idea that the authors expect future changes, to me, sounds like the movie makers who make Spiderman, knowing that the first movie will kick off a few series of films.
The draft of the document will be displayed for public comment from Wednesday until April 20 at www.dsm5.org, allowing for input from individuals and organizations who may feel they’ve been left out of the revision process. I wonder how this will fly.
In light of my upcoming presentation on “The Angry Child” I have been pleased to read that the writers of DSM 5 are considering adding a childhood disorder called “temper dysregulation disorder with dysphoria”. For the majority of kids with temper issues, this diagnosis makes much more sense than bipolar disorder. The hope is that this diagnosis will tilt doctors to recommend behavioral interventions before psychotropic medication, although I am not sure that changing the name will in fact change the treatment algorithm. . Further, as Edward Shorter, a historian of psychiatry, says “the bad news is that the scientific status of the main diseases in earlier editions of the DSM-the keystones of the vault of psychiatry-is fragile.” For example, if a child is a victim of severe physical abuse, the child becomes angry, but if the assessment is not done carefully, that child will be labeled with “temper dysregulation disorder with dysphoria.” As with all diagnoses in psychiatry, the question is how much of the behavior is internally driven and how much is externally driven. When we give a child a diagnosis we are implying that the majority is internal. This is a slippery slope of blame, unnecessary medications and misunderstanding.
I want to go back to DSM II, published in 1968. This listed 182 disorders and was 134 pages long. Symptoms were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems, rooted in a distinction between neurosis and psychosis. Sociological and biological knowledge was also incorporated in a model that did not emphasize a clear boundary between normality and abnormality. The DSM III, with Robert Spitzer MD, at the helm, published in 1980, was the watershed event in that it was 494 pages long and listed 265 diagnostic categories. Spitzer argued that “mental disorders are a subset of medical disorders.” The categorical approach assumed each particular pattern of symptoms in a category reflected a particular underlying pathology. The psychodynamic view was abandoned in favor of a regulatory model. Sigh!
The truth of the matter is that our diagnoses are by and large, not scientific. As scientists, we psychiatrists, need to admit this. We should stop pretending that we know what is wrong with people when we don’t. This post is yet another plea for humility. I can hope.