So here’s the news you might have seen with some flagrantly bizarre and inaccurate headline on HuffPo: the National Institute of Mental Health has withdrawn support from the Diagnostic Statistical Manual (DSM), the manual used to diagnose mental illness, just before it was to come out with its fifth edition. (It came out Monday of this week.) NIMH withdrew support because they consider the DSM to not be valid. What does all this mean?
Let’s first talk about this DSM. Here’s how it got started, way back in 1952: a group of psychiatrists got together and talked about the things they saw in the patients they were treating. They noticed similarities, so they hashed it out and came up with diagnoses (and really, disorders), based on the symptoms they saw in their clients. Then they put them in a book. That book has changed significantly over time, but the criteria for mental illness continues to be based on the behaviors you see a person doing, and what they report to you.
This has always been problematic for a few reasons-
1) Even psychiatrists have a hard time being objective about the behaviors they see in their clients- very concrete behaviors to count, MRIs, watching dopamine levels- all are better than your opinions on how people seem unhappy, or how they say they’re unhappy.
2) They normed pretty much every diagnosis on white men, so if you don’t experience depression like a white man but you are depressed, you may be SOL. I have a real soapbox about how African-American men, to me, often experience depression differently than white men. What I have seen as depression is labeled as schizophrenia, and then the men are drugged up within an inch of their lives with tranquilizers when they are actually just depressed.
3) It’s a bit of putting the cart before the horse. They saw these symptoms and decided they were related and called them _____, so if you have these same symptoms, you are also _____. It doesn’t address etiology or context. A person who lives in a hot, rat-infested house with ten other people is going to have so many other emotions- rational emotions- occurring on top of whatever depression and anxiety they’re genetically feeling, but none of that is addressed with our current system. There’s a spot in the diagnosis paperwork where you can list “psychosocial stressors”, but never does that actually affect diagnosis. Usually it’s just a list you look at and go “well no shit you’re depressed”.
4) Some patients, especially teenagers, know exactly what professionals are looking for and will fake themselves “crazy” for so long that they eventually lose themselves in it.
From NIMH director Thomas Insel:
“While DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each.” “The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. ”Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.”
Now, let me tell you from a lowly talk therapist’s perspective: as it was not my job to prescribe psychotropics that would change brain chemistry, but rather to help a person learn coping skills for their own symptoms that make them uncomfortable, so for me, diagnosis was never that important. I worked hard (and I’m no saint- it was sometimes difficult to do when I had a massive case load), to see all my clients as individuals, rather than diagnoses. I saw the DSM, and diagnoses, as slight guideposts, but more importantly, as the way that my clients’ treatment was paid for by insurance. So I learned to work it the best I could. The DSM is not perfect, never has been, but it’s all we have currently.
So what does NIMH want to use instead? They have put together a project called the Research Domain Criteria (RDoC), where they are looking to diagnose disorders based on concrete biological changes alongside behavioral changes. Their aim is to combine clinical observation with genetics and neuroscience to get a better picture of what’s actually going on inside and outside.
This is a long range project, NIMH says, but in the mean time, they aren’t paying for any more research that would bolster the DSM. The goals feel a bit lofty to me at this point, as I have worked in some backwoods tiny mental health clinics that don’t have copy machines, let alone MRIs, but I think it’s a step in the right direction.
RDoC could have huge implications for medication, but I would like to think that it won’t change the job of a talk therapist, who is always just supposed to put together a toolbox to use for each person in front of them.