The Diagnostic and Statistical Manual of Mental Disorders has been called the “Bible” of mental health, but major players in the mental health community say the book needs more research.
The changes made in the newest version, DSM-V, allow doctors to diagnose depression earlier and change clinical subcategories of ADHD, bipolar disorder, schizophrenia, and more.
The book is receiving a lot of criticism because the disorders it describes are classified as groups of symptoms, but critics say the authors don’t take into account many other important factors for diagnosis.
NIMH Distances Itself From the DSM
This week, the National Institute of Mental Health (NIMH) distanced itself from the DSM-V, which will be released later this month. Their main complaint is that the DSM lacks validity because it classifies disorders solely by their symptoms.
NIMH director Thomas Insel said mental health patients deserve better than that, and that the organization's research will be reorientated away from DSM categories.
“Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever,” he wrote on the NIMH website.
The NIMH isn’t the only organization to take issue with the DSM's review process, but that doesn’t mean every mental health professional will abandon the book.
Rob Dobrenski, a psychologist in New York City and author of Crazy: Notes On and Off the Couch, said that while his relatively narrow practice scope doesn’t warrant a daily viewing of the DSM-IV, he does see it as a useful tool.
“The brain/mind is the most fascinating and, at the same time, frustrating field of study,” he said. “Human experience is so vast and comprehensive that no single book will ever adequately address it. That said, the field is slowly but surely moving in the right direction.”
The Need for a New Review Process
In the journal Health Affairs, professors and researchers from Columbia and Rutgers Universities argued that the DSM revision process doesn't have a systematic way to account for population-level variations and that it misses major points, including environmental factors that trigger biological responses, cultural perceptions of abnormal behavior, and institutional pressures, such as pharmaceutical marketing or disability benefits.
They proposed an independent research review body to monitor diagnostic variations, recommend new avenues of research, and identify changes in mental health policy.
To address these and other concerns, the NIMH established the Research Domain Criteria (RDoC), a framework for collecting data on mental illnesses to create better diagnoses not rooted in DSM criteria. For example, a clinical trial may involve all the patients in a mood clinic, rather than just those who meet the diagnostic criteria for major depression.
“We are committed to new and better treatments, but we feel this will only happen by developing a more precise diagnostic system,” Insel said.
There's no reason why the RDoC can't “inform” the DSM, Dobrenski said.
“The research community will, of course, be greatly impacted [by the RDoC], although it's still speculative what effect it will have in terms of practice,” he said.
A last criticism lobbed at the DSM is that its newest edition broadens the definitions of many mental illnesses to the degree that they become almost meaningless. Is it possible that according to the DSM-V the majority of Americans now have a diagnosable mental disorder?
“I've always preached that everyone is crazy, it's just a matter of degree, duration, and timing,” Dobrenski said. “Take a look at the current DSM—if you have a lot of time to kill. There are some incredibly benign diagnoses in there, at least one for pretty much everyone out there, myself included.”