The DSM-5 Controversy

Look for an upcoming interview series right here on HCPLive.com and in the pages of MDNG: Neurology/Psychiatry editionwith the key players involved in the development, as well as the criticism of, DSM-5, including Dr. Robert Spitzer, lead editor of DSM-III, and Dr. Michael First, head of the Prelude Project for DSM-5, designed to solicit feedback before the revision.

The following was originally posted to Shrink Rap.

I've followed in bits & pieces. Sometimes for Shrink Rap, sometimes because the issues fill my email in-box, sometimes because there's no escape. Oh, and lots of the players have familiar names.

In the December 27th issue of Wired, Gary Greenberg writes a comprehensive article on the debates around the revision of the American Psychiatric Association's upcoming revision of the Diagnostic and Statistical Manual. So, "Inside the Battle to Define Mental Illness." Do read it. Here's a quote:

I recently asked a former president of the APA how he used the DSM in his daily work. He told me his secretary had just asked him for a diagnosis on a patient he’d been seeing for a couple of months so that she could bill the insurance company. “I hadn’t really formulated it,” he told me. He consulted the DSM-IV and concluded that the patient had obsessive-compulsive disorder.

“Did it change the way you treated her?” I asked, noting that he’d worked with her for quite a while without naming what she had.

“No.”

“So what would you say was the value of the diagnosis?”

“I got paid.”

As scientific understanding of the brain advances, the APA has found itself caught between paradigms, forced to revise a manual that everyone agrees needs to be fixed but with no obvious way forward. Regier says he’s hopeful that “full understanding of the underlying pathophysiology of mental disorders” will someday establish an “absolute threshold between normality and psychopathology.” Realistically, though, a new manual based entirely on neuroscience—with biomarkers for every diagnosis, grave or mild—seems decades away, and perhaps impossible to achieve at all. To account for mental suffering entirely through neuroscience is probably tantamount to explaining the brain in toto, a task to which our scientific tools may never be matched. As Frances points out, a complete elucidation of the complexities of the brain has so far proven to be an “ever-receding target.”

What the battle over DSM-5 should make clear to all of us—professional and layman alike—is that psychiatric diagnosis will probably always be laden with uncertainty, that the labels doctors give us for our suffering will forever be at least as much the product of negotiations around a conference table as investigations at a lab bench.

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