THE FIFTH EDITION of the so-called bible of psychiatry, the Diagnostic and Statistical Manual (DSM-V), has just been published by the American Psychiatric Association (APA). This is the manual that explains the increasingly common bipolar disorder and sorts out your social phobias from your antisocial personality disorders. It’s an important book.
The response to the latest edition has been mixed, as expected, but a consensus is that the threshold for diagnosis has been lowered and that more of us will now qualify for a mental disorder. Critics highlight the inclusion of a range of new disorders such as social (pragmatic) communication disorder (you figure it out) and amendments like the omission of the bereavement exclusion for a major depressive disorder. Put simply, the death of a loved one can no longer be used to explain away symptoms of depression in the months following death.
In any case, as the APA explain, “the depressive symptoms associated with bereavement-related depression respond to the same psychosocial and medication treatments as non–bereavement-related depression” so why not make bereavement related sadness a disorder?
Of all the revisions to the DSM-V (version IV was published in 1993) the most telling and significant is the change in terminology where the phrase “general medical condition” is replaced in DSM-V with “another medical condition”. This subtle change is intended to reinforce the medical validity of psychiatric diagnosis, just like other medical conditions. The DSM-V is the bible of psychiatry and mainstream psychiatry claims scientific validity as a medical science.
Psychiatry went through something of an identity crisis in the 1970s in the face of the popular anti-psychiatry movement which portrayed the brutality of mental asylums and questioned the very existence of mental illness. Meanwhile psychodynamic models of treatment from the therapist’s couch dominated private practice. In response, in 1980, the American Psychiatric Association published the third edition of the DSM which was an expression of a new paradigm.
The significant difference between the 1980 DSM III and earlier versions was that this new manual was categorical. It presented fixed disease categories based on the presence of clusters of symptoms. A biomedical model of mental health was born and the paradigm in mental health had shifted to one where the role of a person’s story was diminished and the importance of the organic functioning of the brain took centre stage.
Our understanding of all aspects of human life is based on the acceptance of certain knowledge (the dominant truth), which in turn informs our practices and reinforces our very identity as human beings. The sociologist Nikolas Rose talks about the shift in paradigm in mental health towards a biomedical understanding being accelerated by technological advances in computerised brain imaging. Through the development of magnetic resonance imaging (MRI) scans and other new technology in the latter part of the last century was it now possible that we could actually view madness in the brain?
With the publication of DSM III with its literal definition of a greatly increased number of mental disorders and advances in brain imaging a new narrative in mental health took hold. This narrative was based on a medical understanding of mental health, it facilitated medical, drug-based, responses to mental health problems and the emergence of what Rose describes at different points as us humans identifying as “biological beings” and “neurochemical selves”.
This version of the truth about our mental health relies on the chemical imbalance theory of mental health problems, the effectiveness of medication in fixing that imbalance and the ability we possess as human beings to manipulate our biology (through exercise or eating chocolate) in order to mind our mental health.
There is more to human beings than biology and our mental health, for better or worse, is not determined by brain function alone. While few would dispute that life experiences influence our mental health the dominant truth tells us to start elsewhere (the brain) in our attempts to help ourselves or each other through mental health problems. Psychiatry’s DSM reinforces a disease-centred model of mental health and the idea that there is something fundamentally wrong with a person who is persistently depressed or anxious. Something that can be fixed by the use of medication.
When we are encouraged to ask the question “what’s wrong?” we generally fail to ask the question “what’s happened?”. The DSM is important because it reinforces this way of looking at our mental health. The DSM is also important for paradoxical reasons. Its publication is open and transparent and anyone can access its list of symptoms and disorders. For private health insurers it provides an invaluable checklist of symptoms and diagnoses against which they can assess clients’ treatment costs and reimbursements.
Some recent research from the United States by Owen Whooley reports that doctors there admit to using what they call ‘workarounds’ whereby they willingly apply the relevant diagnostic label to make sure the insurance company will reimburse treatment costs while addressing their clients’ issues from a more holistic perspective. Whooley quotes one psychiatrist who participated in his research discussing the DSM as follows:
“we all fudge. In order to meet insurance requirements we all fudge, we distort the diagnoses. Very often we use a diagnosis that will be acceptable…So everybody has a major depressive illness. In order to deal with insurance requirements, you have to distort it”.
Some, like Dr. Simon Wessely from the Royal College of Psychiatry in the UK argued recently in an article in The Observer that the publication of DSM-V is no big deal. Wessely argues that the manual serves only as a map that is subject to change and revision and that its relevance in practice this side of the Atlantic is minimal. On the one hand this is true. DSM-V is not radically different from the two previous versions. However, while in practice doctors may only use such manuals as a guide (in Europe the International Classification of Disease, ICD, is more commonly used), the impact of the DSM goes far beyond the clinician’s room because in effect the DSM is the foundation on which the medical model of mental health is built.
Doctors no doubt find diagnostic manuals useful in their daily practice and perhaps there is a role for a listing of typical symptoms that tend to cluster and ‘present’ in typical ways. However, our mental health should not be defined by such reductionist diagnostic systems. There is an imbalance in how we in western cultures conceive of mental health with an inappropriate weighting towards biomedical understanding. This is something that is increasingly being recognised and affirmed by a range of mental health professionals, including those involved in the critical psychiatry network.
Critical psychiatry challenges the notion that mental health problems can be explained within a purely medical framework. Until the influence of classification systems like the the DSM is diminished a mandate and logic underpinning such medical understandings of human experience will prevail.
Derek Chambers is the Director of Programmes and Policy for ReachOut.com an initiative of Inspire – follow on Twitter at @ReachOutIRL.
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