It is likely that at some point in your life, either you or someone in your inner circle has been given a mental health diagnosis that was predicated on the DSM. So, what does that mean, exactly?
DSM stands for Diagnostic and Statistical Manual of Mental Disorders. Published by the American Psychiatric Association, it is used on a daily basis by doctors and clinicians around the world. Its fifth revision, aptly named DSM-5, is due to be published in May, 2013.
Why is it important to know about this book if you are not a doctor, clinician, researcher, health insurer, etc.? First, I want to outline a little bit of the history of the DSM, and then I will share my thoughts on its importance to us, the consumers of mental health services.
The very first edition of the DSM came out in 1952. It was 130 pages long and listed 106 mental disorders. It was updated again in 1968 and 1980; both the page count and number of disorders grew significantly.
The version of the DSM that is currently in use is the fourth edition, published in 1994 and then given a slight ‘text revision’ in 2000. It now stands at 943 pages and lists 365 disorders, more than three times as many as were identified in the original version of the book. While the development process for DSM-5 is closed, there has been opportunity for the public to review and comment on the proposed changes and the word on the street is that the list of disorders is expected to grow yet again.
Is the DSM growing because mental health researchers and practitioners are identifying new disorders and/or better specification of existing brain disorders, or are they creating new categories for standard human behaviors? Allegations that the DSM continues to ‘increase the medicalization of human nature’ are coming from all corners, including, interestingly enough, the doctor who acted as the chair of the DSM-IV Task Force, Allen Frances. He has an entire web page of articles posted on Psychology Today under the banner DSM5 in Distress.
The reason why I believe that the growth trend of the DSM is important to us is because invariably, along with the increase of listed mental disorders there has been an increase in diagnoses. That trend has been noted over and over again in the last 30 years. But here’s the key: a diagnosis of a mental disorder can set into motion a treatment plan that has far-reaching ramifications for the person who receives it. And why do I say that? Because often the treatment plan includes medication, and often the use of medication stretches from months to years to decades, and that can be a very serious matter. There can be side-effects, decreasing efficacy, and long-term cognitive impairment, not to mention that medication costs money.
I probably should make a statement here: I am not anti-medication. I believe that it has a role, and that every person’s case is different. There is also a giant spectrum between someone who is in crisis vs. someone who is feeling more stress or anxiety than usual, and everything that falls in between (children and their temper tantrums, for instance). Some people are in the fortunate position of having more time to see how things develop or progress before trying to assign a firm DSM-type diagnosis and starting down a medication treatment path.
It is our awareness of the trends that are afoot, however, that put us in a better place to ask questions when we are seeking help and receiving diagnoses. Could you (or your family member or friend) seek a second opinion, or are there notes from visits to different kinds of practitioners that need to be compared before a fully-formed opinion can be communicated?
Practitioners often come with their own bias, too, so it is also good to be tuned in to where they stand in terms of mental disorder diagnosis vs. human nature and behaviors. To give a brief example, I sat with a therapist once and said, “Since I’m feeling X, Y and Z, am I depressed?” Her response was, “Well, you’re certainly feeling pretty crummy about something. Let’s try to figure out what that’s about.” Her reluctance to answer my original question with a diagnosis at first exasperated me, but after a while, I understood her approach and appreciated that maybe it wasn’t so important, at that point, to diagnose me with a named condition. Rather, we worked on how I could move through the feelings that I was having (which I did, thankfully).
Really, the bottom line is this: I wouldn’t be writing about DSM’s growing list of disorders if I wasn’t so alarmed by the growth in mental illness diagnoses in the United States. For instance, just in the last two decades, the number of mentally-ill children (who were diagnosed and eligible for a disability payment) rose thirty-five fold. Mental illness is now the leading cause of disability in children in the U.S. Environmental changes may be a contributor, but the numbers are so staggering that there has got to be more behind it.