The new revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the long-standing resource of mental health diagnoses, has been met with criticism from virtually every corner of mental health advocacy. Despite the often-aggressive criticism of the DSM, however, many mental health experts were surprised when the National Institute of Mental Health, which is the largest organization of mental health research, and a significant source of funding for mental health researchers, issued a statement that was harshly critical of the updated manual, the DSM-V.
Headlines in the popular press have treated this development as a shock to the mental health world and a complete torpedoing of the DSM. The reality, however, turns out to be a lot more nuanced. The NIMH is not withdrawing support for the DSM-V. Instead, it is developing its own mental health diagnostic system that it believes will be more useful than the DSM. The NIMH’s statements about the DSM in recent months have been very critical, and a statement on the NIMH website reads, in part, “Patients with mental disorders deserve better.”
The NIMH’s Concerns
The NIMH has raised several concerns about the new DSM-V in particular, as well as general traditions in diagnosing mental health issues. Particularly troubling to the NIMH is the fact that mental health diagnoses are based primarily upon symptoms, and that experts diagnose diseases based upon agreed-to symptoms rather than tests, such as blood work. This, argues the NIMH, makes the diagnostic standards in the NIMH less valid than diagnostic standards in other areas of medicine.
Noah Rubinstein, GoodTherapy.org founder and CEO, said, “It makes sense that NIMH, in its support of the disease model of mental health, would focus on biological markers rather than symptomology, and thus reject the DSM-V. However, the purpose of the DSM‘s historical focus on symptoms is to remain atheoretical and preclude any explanation about the etiology of the various diagnoses.”
The NIMH’s new mental health diagnostic guidelines might not please many critics of the DSM. The new model will focus on biological psychiatry, a field that understands mental health disorders as diseases caused by problems with brain chemistry or the nervous system. “For many of the syndromes listed in the DSM, underlying causes have always been up for interpretation, and the APA has not wanted to take a theoretical stance,” Rubinstein said. The NIMH intends to work on uncovering genetic markers for mental illness as well as brain pathways and nervous system functions that can contribute to the development of mental illness. Diagnostic criteria will then be based around biological functions rather than similar symptoms.
But there are reasons to hesitate about this approach. “Indeed, there are some mental health disorders that could be argued as purely biologically based,” Rubinstein said. “However, many of the issues that bring people to therapy do not necessarily have biochemical origins. These issues include adjusting to life changes, grief, self-esteem issues, anger, relationship problems, certain forms of dysthymia, anxiety, and many others.” Rubinstein predicts that, “unfortunately, as problematic as the APA’s DSM-V is, NIMH’s version will do no better.”
What It All Means
For generations, psychiatry has diagnosed patients based upon symptoms, and disorders have been treated as similar when they have similar symptoms. Under the NIMH model, however, two disorders that seem quite similar might fit into completely different diagnostic categories. The change also could mean that the NIMH will be less likely to fund research that does not focus on biological psychiatry.
This change could be a problem for some philosophies of mental health. Treatment that focuses on altering a person’s environment while also treating his or her brain—for example, by encouraging meditation and the development of relationship skills in conjunction with antidepressants—might begin to fall by the wayside.
“There is so much interplay between the environment and biochemistry—between what happens to us, around us, and inside of us,” Rubinstein said. “It is illogical to claim, for example, that the cause of a person’s depression is biochemical, when the biochemical imbalance could just as well be a result of spouse abandonment. In other words, biochemical imbalance can just as easily be viewed as a symptom.”
What Happens Next?
There’s no way to predict how the NIMH’s diagnostic criteria will end up looking. It may be that some illnesses don’t neatly fit into a single category or that researchers can’t yet determine the physical causes of some disorders. It could be that some disorders are a product of environment, and it’s likely that many disorders are likely the result of a complex interaction between the environment and the genes.
Rubinstein seems optimistic that this interaction may be considered soon. “I imagine that future research will try to tease out what comes first, the biochemical change or the environmental event, in an effort to identify true mental health issues,” he said. But he acknowledges that this work is “complicated, and perhaps impossible,” and ultimately, until this research is accomplished, he says “the NIMH diagnostic guidelines will remain biased, limited, and inaccurate.”
Rubinstein is not alone. Mental health advocates who argue in favor of holistic approaches to treatment are unlikely to be satisfied by the NIMH’s position. Some advocates have objected that the DSM pathologizes normal behavior or that the addition of new diagnoses is an attempt to label everyone as mentally ill. The NIMH’s approach doesn’t answer this critique, but it is likely a welcome answer to advocates who have long argued that the DSM‘s diagnostic criteria are unscientific.
- Grohol, J. M., Psy.D. (n.d.). Did the NIMH withdraw support for the DSM-5? No. Psych Central.com. Retrieved from http://psychcentral.com/blog/archives/2013/05/07/did-the-nimh-withdraw-support-for-the-dsm-5-no/
- Transforming diagnosis. (2013, April 29). NIMH RSS. Retrieved from http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml
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