Saturday
22 November 2008
22 November 2008
| Grey Lady Down: The Wreck Of The DSM |
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| Opinion - Looking Glass | |||
| Written by Sharon Gaughan | |||
| Friday, 18 July 2008 17:00 | |||
Washington, DC, USA. The Manual for Diagnosis of Mental Disorders (DSM-V) has long outlived its intended purpose, the legitimization of psychiatry as a medical discipline. Even if we forgive the suspect origins of the DSM and respect the intentions of subsequent generations, the book β and that is what it is β has been overtaken by events.
The American Psychiatric Association (APA) has begun work on a revised version, the DSM-V. There is considerable discussion within the caring professions on how to express various conditions and disagreement on whether some of them should even be included in the DSM-V.
But this is like trying to put a new coat of paint on a ship as it slips beneath the waves.
Science and medicine have progressed apace, but psychiatry has nowhere near the acceleration of the other disciplines upon which it depends. The genome, the entirety of an organism's hereditary information, has been known to scientists since the 1920s. The 1950s saw the description of DNA. The pace and sophistication of scientific findings from embryology and neurobiology has accelerated ever since. Those are just some of the milestones among many more.
And psychiatry? The DSM-IV reached publication in 1994 (with a minor "text revision" in 2000). The DSM-V is currently in consultation, planning and preparation, but it isn't due for final publication until May 2012. Hard scientific research has already outstripped the DSM. I seriously doubt that the DSM-V will be up-to-date upon its publication.
Clinical psychoogists start with triage, sorting out normal, stressed out β perhaps even eccentric β people from the truly pathological. A growing number of mental health professionals criticize the lack of an empirical foundation for the DSM. They stress that it has become a bloated compendium of incomprehensible symptoms, vague descriptions, and arbitrary time limits. No law, regulation, or standard is worth much if it can't be implemented. One thing we know for sure: for good or ill, there are increasing numbers of caregivers, clients, and patients who simply ignore the APA and the DSM.
The APA emphasizes that the revision will be evidence-based. They should know: one of the leading psychiatrists in the United States has promoted the evidentiary approach throughout his career. He has attained academic honors and the respect of his peers. I am talking, of course, about Paul McHugh, a featured player who allows his religious beliefs to abridge his professional responsibilities. [Briefing: Roman Catholicism And Harry Benjamin Syndrome (HBS)].
If all entries in the DSM are perceived as equating a mental disorder with a mental illness, then many of the existing entries are candidates for deletion. After a protracted struggle, the APA deleted homosexuality from the DSM-IV revision. Nowadays, one can be homosexual and in therapy for difficulties in social adjustment related to coming out as a homosexual but not for the underlying orientation. Harry Benjamin Syndrome (HBS) is unrelated to sexual orientation, of course, but it too is a major area now up for reexamination. Commonly known in the DSM as transsexuality, the general principle applies: one can be HBS-born and in therapy for adjustment difficulties, but not for the underlying birth condition. And so on.
Even so, HBS is by no means central to the debate over the DSM revision. All this talk about a new, improved DSM, one that is based on evidence and responsive to the actual situation of human beings is just that β talk. Moreover, it avoids deeper considerations, such as the organizing principles that should structure the revision.
The DSM is sourced from a combination of traditional practice that emphasized judgements about perceived behaviors and their impact on the social context within which the behaviors occur. So, a child's launch of an occasional facial tic to annoy a sibling is subject to parental correction. That most often works, but if it turns out to be a chronic tic then the parents can enlist psychiatric intervention. I offered that example on purpose. After all, and all things being equal, it seems to imply a neurological source.
But the trigger point has become more immediate over the years, obscuring the difference between ordinary discipline problems and genuine medical conditions. Impatience has a direct affect on whether a problem is pereived as chronic. That is how too many psychiatrists approach such problems (usually with a prescription in hand). The APA likes to emphasize that their DSM is for diagnosis, leaving treatment as another β later β step in the process. But if their diagnostics are flawed, how then can the treatments be trusted for their efficacy?
Some scientists believe that psychiatrists and psychologists have extended the term disorder beyond a baseline scientific understanding that disorderly systems are merely those that exhibit behavioral properties outside of expected structural expectations.
The APA's certainty about the source of what they term disorders persists, even in the face of growing evidence that neurobiological conditions are not transparent to traditional psychotherapy. Moreover, the ignore the cumulative impact from a large number of genes that place an individual at risk. Each of the genes conveys a relatively small component of vulnerability. Factor in non-coding DNA and glycomics and you have an exciting prospect for the relief of human suffering. The DSM may well evolve into a history book that lists all of psychiatry's lost opportunities for accomplishment.
The APA begs all of the important questions and takes it for granted that we really need another DSM. But what is the purpose of the DSM in the first place? If the DSM is intended as the authoritative diagnostic reference, then what is actually included in the manual becomes crucial. Why include adjustment problems? If we separate life style adjustment from true pathologies, why not publish the criteria in two separate volumes? The APA says it is "Member Driven. Science Based. Patient Focused." Apart from the questionable ordering of their priorities, is the APA the best entity to develop a diagnostic manual in the first place? Throughout my professional career I noted that organizations grew from their founding, crested, and declined. Somewhere in that cycle sleepy executives would awake to the situation and attempt a revival.
Trouble was, the same people who got us into trouble were now entrusted with getting us out of trouble.
Oh, DSM, it is time to let you slip beneath the waves and sleep in peace. The rest of us can return to our drawing boards and try to get it right next time.
 Ms. Sharon GaughanΒ is the Co-Founder, VP, and Executive Director of TS-Si, Inc. She also serves as the Managing Editor and columnist for the TS-Si website.Β Ms. Gaughan's signed articles contain her own opinions and do not necessarily convey an official position of TS-Si, its partners, or affiliates. Β
Sharon welcomes your comments. You can use the public form below or send private correspondence via her TS-Si Contact Page. We will not divulge any personal details or place you on a mailing list without your permission.
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