Not Perfect, but Not Bad: Why I Love the DSM-5

David MaysEditor’s note: A practicing psychiatrist for more than 23 years, David Mays, MD, PhD, is the clinical director of Mendota Mental Health Institute—once known as the Wisconsin Hospital for the Insane. His continuing education presentation for GoodTherapy.org, titled DSM-5: Ready or Not, is scheduled for 9 a.m. PDT on April 11. It is one of two DSM-related continuing education events scheduled for April, each offering a unique perspective on mental health’s guidebook. This event, free to GoodTherapy.org members, is good for two CE credits. For details, or to register, please click here.

In 1860, the Wisconsin Hospital for the Insane opened outside Madison. It was Wisconsin’s first mental health facility. People began checking in early on a Friday, although the hospital was not to open until the following Monday. The diagnoses given to these early admissions by the hospital administrator included: “business perplexities,” “worms,” “softening of the brain,” “insanity due to the improper conduct of wife,” and “study and novel reading—age 11.”

We don’t have billing codes for these “issues” today, perhaps in part because in 1952 the American Psychiatric Association reached into its coffers and paid to publish a Diagnostic and Statistical Manual of Mental Disorders. At the time, there were 39 classification systems for “mental disease,” all reflecting different theoretical orientations and emphasizing different features of mental disorders—behavior, course of illness, prognosis, etc. Ten percent of the membership of the APA voted and said, “Here is the true list of mental disorders.” Thus, DSM-I was born. “Softening of the brain, “oral passive character,” and “anal aggressive personality” were out; “organic brain syndromes,” “functional disorders,” and “mental deficiency” were in.

Over the years, quite a few diagnoses have come (schizoaffective disorder, premenstrual dysphoric disorder, conduct disorder) and gone (passive-aggressive personality, homosexuality, Asperger’s syndrome). But with each revision, the DSM has applied the principles of scientific inquiry—exhaustive literature reviews, re-analyses of the data, clinical field trials—to try to increase reliability and reduce unsupported theoretical bias. Of course, each DSM version is a flawed document. So is my chemistry textbook from 1975. But science trudges forward. What seems like a “two steps forward, one step back” process reflects the slow refinement of consensus as to what can go wrong with the human brain.

Mental health issues are devastating. They can strike early. They are relatively common. They can be debilitating throughout a normal lifespan. Add to that the stigma of “defective character,” “spiritual depravity,” or “moral insanity” and you are piling on suffering. The DSM, as a document based on the so-called medical model, offers people with severe mental issues an idea they can relate to: I am not a bad person; I have an illness.

There are a number of mental health professionals who cannot utter the words “medical model” without narrowing their eyes and curling their lips in a contemptuous sneer. Science, allopathic medicine, the medical model—I admit it: I’m a fan. All of my children survived to adulthood. I did not get, nor do I have any acquaintances with, polio. I still have all my teeth into my sixties. These were all rare events less than a century ago. I’m glad we know that “refrigerator mothers” do not cause autism and that 90% of sexual dysfunction is not due to psychological conflict; it is due to circulation and hormone changes. Progress in mental health research lags painfully behind the other medical specialties. After all, the human brain is the most complex structure we know of in the universe. But when it comes to finding the cure for Alzheimer’s, I am placing my bet on the laboratory, not the herb garden.

Of course, it’s complicated. Not every issue in the DSM is a brain disorder. An angry, aggressive child from an abusive, chaotic family, or a thunderstruck spouse learning of a partner’s affair, doesn’t have a brain disease. Such people are miserable, vulnerable to bad choices, and under severe stress. Unfortunately, managed care forces us to make a diagnosis in order to provide help. This is beyond a distortion of the reality of the situation. It is unfair, damaging, and does not reflect what we know about human beings and how they are connected to what is happening around them. The DSM can easily aid and abet this confusion—the difference between asking the question, “What is wrong with you?” versus, “What happened to you?”

So I lied. I don’t love DSM-5. I wish it were more exciting, filled with dramatically colored qEEGs and fMRIs, cataloguing all the biological markers that distinguish the normal from the pathological. I wish there were better clarity in separating brain diseases from brain adaptations. I wish the “key opinion leaders” on the DSM task force didn’t all pay their academic dues by doing research for Big Pharma. I wish we had a lot of choices of nontoxic, natural, effective treatments for the things that make us miserable.

But it isn’t, there isn’t, they did, and there aren’t. “DSM follows the field; it does not lead it,” as one researcher commented during a presentation on DSM-5 criteria for attention-deficit hyperactivity. This is science. DSM is a textbook. We have to wait for the evidence. It is maddeningly slow. But at least 11-year-old girls don’t get diagnosed anymore with “study and novel reading.” I’m really happy about that.

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  • Gary

    Gary

    March 25th, 2014 at 10:25 AM

    This may be the first time I have read anything that makes any sense to me about the new DSM manual. No it isn’t going to address every single issue out there, nothing ever is, and it won’t have the answer to every single problem. But I guess that it is making some progress and I guess that’s all we can ask for. I think that there are many who would like some more definitive answers and those who care the most are always going to be striving toward providing that so in the meantime this is goingt o be the guidebook for professionals to go by. It doesn’t always offer the clear cut answer but maybe it can offer some of the missing clues that have been the missing pieces and this can help you better put that puzzle together using the provided information.

  • Jill

    Jill

    March 25th, 2014 at 3:16 PM

    And you have to admit- it is better than just letting everyone make their own determinations- it is better to have a little guide than nothing at all

  • Lola

    Lola

    March 26th, 2014 at 3:51 AM

    Well I have to say that after reading some of those forst diagnoses cited, then I am certainly glad that we have moved past some of those!
    But there is still room to improve, as tnere should always be. We should never be satisfied with what we have, we should always want to get better, no matter what we are doing or what field we are in.
    Don’t be satisfied with just being ok, always strive to do better.

  • ken

    ken

    March 26th, 2014 at 4:18 PM

    But this is not all encompassing, it still misses a whole lot, and I am sorry to say that in many cases it still misses the boat.

    Is there ever going to be a manual that will get it all right or is that destined to be an arm of medicine that is just too subjective for that?

  • nori

    nori

    March 27th, 2014 at 3:45 AM

    can anyone tell me how often the revisions are made and why it seems to take so long to put out new guides? and why is there so much dissension in the ranks anyway?

  • Janna

    Janna

    March 27th, 2014 at 4:08 PM

    The real reason that most people are so put out with all of this is because they know that they can do better and that those in the mental health care community, professionals and patients alike, all deserve better.

  • Christina S

    Christina S

    March 28th, 2014 at 3:51 AM

    I suppose that until there is something better that comes along this is what you have to go by so it is what it is. I hope that you don’t mean that much of what is included is totally dictated by big emdicine though? That would make me really sad to step back and think for even one more minute just how much they have been allowed to inflitrate even this part of the medical field.

  • les

    les

    March 29th, 2014 at 5:02 AM

    there has been refinement
    there have been improvements
    and we are never going to make everyone happy

  • Xavier

    Xavier

    March 30th, 2014 at 9:16 AM

    hahaha The title of this cracked me up cuz I knew in some way you had to be joking. And I guess I could see how you could be a little serious about it but for the most part I get it, you love it for the fact that it is making progress but there is always in this area of medicine going to be room for improvement, there just will be.
    We are always hopefully learning and growing and discovering as we go along so there are always going to be more opportunities to learn new things, and that could be the one chance discovery that could make a real difference to a whole new group of people.
    So we can’t stop now, we all still have to continue to be advocates for change, but we can celebrate the small steps in the right direction.

  • peyton j

    peyton j

    March 31st, 2014 at 2:44 PM

    Isn’t it sad though that research into one of the most important elements of the human body lags so far behind the research of other areas?

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