To laymen, psychiatry can still come across as theoretical, more difficult to grasp than other branches of medicine: The difference between a bloody foot and a bruised soul. But over the course of its history, the DSM has been a mirror, reflecting whatever is ailing society and providing a vocabulary with which to discuss it. The language of the DSM has been embraced (misused?) by the masses, aiding in the self-description, self-labeling and self-analysis that have defined the 2000s and 2010s. We are “a little bit OCD,” with bosses who are “classic narcissists.” We are dating boyfriends who might have generalized anxiety disorder.
The DSM takes that bruised soul and gives it a name. Which gives us peace of mind.
If something is wrong with all of us, is anything wrong with any of us?
Concerns and doubts
“I am a lazy, selfish person who has never been involved in a cause before this, but I felt like I had no choice.”
This is Allen Frances, the chair of the DSM-IV task force. The “cause” he speaks of is speaking out against the DSM-5. A few decades ago, his wife had a brain tumor, and he dropped out of practice for a while. When he became involved in the field again, he decided that the field had drifted toward over-diagnosis and over-medication.
Now he has been traveling around the world, spreading this gospel, which is also laid out in two separate books he has written on the DSM-5, and on what he sees as diagnosis inflation and migration.
Frances is one of multiple vocal critics who have expressed doubts about, reservations over, or downright hatred toward the new manual.
Last week, the National Institute of Mental Health, the largest mental health research organization in the world, announced that it had concerns about the DSM-5 and would begin reorienting its research away from DSM categories. “The weakness is a lack of validity,” NIMH director Thomas Insel wrote in a statement, criticizing the DSM-5 for basing its diagnosis on clinical symptoms rather than on “objective laboratory measures.” “Patients with mental disorders,” Insel wrote, “deserve better.”
David Kupfer, the DSM-5’s chair, responded to the NIMH’s concerns by arguing that objective measures, like biological and genetic markers, are still too far off to wait for. “In the absence of such major discoveries,” he wrote in a statement, “it is clinical experience and evidence, as well as growing empirical research, that have advanced our understanding” of many disorders.
Understanding has been advanced — but not reached.
Because even for medical professionals, “fact” is a moving target, a difficult destination. Throughout its history, the DSM has remained a consensus document, says Shorter, the medical historian. “We didn’t [calculate] the speed of light in a consensus document . . . Psychiatry aspires to scientific status,” Shorter says, but it’s also subject to the political or interdisciplinary nuances of the day.
“People don’t change quickly,” says Frances. “Labels change on a dime. Labels follow fashion. Whenever there’s a sudden jump, it’s not because there’s more pathology, it’s because there’s a difference in labeling it.”
It brings up an essential, philosophical question: Who are we? Are we the same people we’ve always been? Sicker? Healthier? Wounded as ever, but with better terminology?
The DSM might relabel our suffering, but does it bring us any closer to understanding the unquiet of our minds?
“We’re very comfortable with what we’ve done,” says James Scully, the APA chief executive, back in his office overlooking the Potomac. “And moving forward, we think it’s a wonderful book, and people get to see it in a few weeks.”
Not that he expects that this is psychiatry’s final destination.
“Will there be changes in the future? I hope so. It’s not the word of God. It’s the best science we have currently,” he says. “This is DSM-5, it’s not DSM-The End.”