Revising Book on Disorders of the Mind

List of psychiatric medications

FmH readers know of my preoccupation with psychiatric diagnosis, its follies and abuses, about which I am more likely to rant here than any other topic (other than George W. bush and his administration). Today, the American Psychiatric Association posted on the web the details fo the next proposed revision, version V, to the DSM (the Diagnostic and Statistical Manual), which is the ‘bible’ of accepted psychiatric diagnoses and their criteria. DSM-V is currently scheduled to come out in 2013 after a period of public comment on the revisions and several years of field trials. The release date has already been pushed back because of controversy about the proposals and the revision process, some of which is pointed to in this NYTimes.com piece.Several different things happen in these revisions. First, the universe of existing mental illnesses is reparsed and some of the afflicted end up going into different pigeonholes. By and large, this is a trend I welcome, as the new distinctions made, and the old distinctions collapsed and erased, appear to be generally in line with the clinical experience of frontline practitioners like myself who spend all our time actually treating the mentally ill. Some of my pet peeves, like the overdiagnosis of attention deficit disorder, of childhood bipolar disorder, and of posttraumatic stress disorder, may be improved. As Gregory Bateson defined it, information is a “difference that makes a difference”, and some of the refined distinctions here will of course be more useful to psychiatric research than to practice, but by and large I find them meaningful.

However, the other thing that goes on from revision to revision of the DSM is a proliferation of diagnoses, leading to a relentless expansion of the scope and incidence of mental disorders among the population. This is what has been referred to as the medicalization of ‘normal’ human variability and of personality differences. If a broader net is cast and more people are diagnosable with mental disorders, you can imagine some of the consequences, which include the increasing use of medications for more and more benign variations; changes in social stigmatization; insurance reimbursement for various states of distress; and various diminished responsibility defenses in criminal proceedings. More profoundly, we are rewriting the concepts of personal responsibility and autonomy and the balance between free will and determinism.

I already have far too much work to do to welcome such a broader net, but then again I don’t make a fortune on the basis of how many prescriptions are written. (Estimates are that anywhere from 50-70% of those working on the revisions derive substantial income or research funding from the pharmaceutical industry.)

Tonight, because one of their reporters has been a reader of FmH, I was interviewed by the BBC about my impressions about the DSM-V proposals. It remains to be seen whether I gave them any juicy quotes they can use.

Revising Book on Disorders of the Mind