In a few weeks there will be a really big event in the world of mental health. The Diagnostic and Statistical Manual of Mental Disorders—commonly called DSM—is psychiatry’s diagnostic bible, and the latest revision of it, DSM-5, is scheduled to be released by the American Psychiatric Association (APA) in early May.
That’s a big deal, since the DSM is an incredibly influential reference; even if you’re not a therapist, you’re likely to be affected by what it says, in one way or another. To give you an idea of how powerful this manual can be, while it sounds unbelievable today, homosexuality was listed as a mental illness in the DSM-2, published in 1968. Forty years ago, political activism forced the APA to abolish homosexuality as a mental illness. In the 1970s, with the rise of gay activism, the fight to stop labeling homosexuality as a mental illness became a major psychiatric-political battle. The APA was fiercely divided on this issue. But gay activism, which included protests at the APA convention, prevailed. Homosexuality as a mental disorder was ultimately abolished in 1973 and excluded from DSM-3, published in 1980.
This time around, with the publication of the first DSM in nearly 20 years, some psychiatrists are upset again by what could be called a “diseasing of normality.” Before the DSM-5 is even officially out, a reform movement has emerged. Can activism again prevail and compel the APA to rethink its pathologizing of normal behavior?
So what does the new DSM reform movement want to see changed? After DSM-5 was approved in late 2012, psychiatrist Allen Frances, the former chair of the DSM-4 task force and currently a professor emeritus at Duke University, was quoted in the New York Times as saying, “This is the saddest moment in my 45-year career of practicing, studying and teaching psychiatry…My best advice to clinicians, to the press, and to the general public—be skeptical and don't follow DSM-5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication.”
Particularly upsetting for Frances is DSM-5’s turning of normal human grief into something pathological. Writing in The Huffington Post in January 2013, Frances said, “Making grief a mental disorder will be a bonanza for drug companies, but a disaster for grievers. The decision is also self-destructive for DSM-5 and further undermines the credibility of the APA.”
Psychiatry should not be mislabeling the normal.
In DSM-4, there had been a so-called “bereavement exclusion,” which stated that grieving the loss of a loved one, even when accompanied by symptoms of depression, should not be considered the psychiatric disorder of depression. Come this spring, normal human grief accompanied by depression symptoms will be a mental disorder.
Frances isn’t alone. The Coalition for DSM-5 Reform is comprised of over 50 organizations, and a petition supporting this protest has already received several thousand signatures from professionals and nonprofessionals. Specifically, the Coalition for DSM-5 Reform is concerned about “the introduction of disorders that may lead to inappropriate medical treatment of vulnerable populations.” Both Frances and the coalition worry especially about the effect of two newly designated DSM-5 disorders: “disruptive mood dysregulation disorder” (DMRD) for kids; and “mild neurocognitive disorder” for the elderly. About DMRD, Frances fears the manual “will turn temper tantrums into a mental disorder,” and that it “will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children,” he wrote in a blog post for PsychologyToday.com. Mild neurocognitive disorder—which is essentially the normal increased forgetting characteristic of aging—could result in unnecessary pathologizing and medicating of the elderly.
If changes to the new DSM move ahead, the threshold for diagnosing many mental disorders may be lowered significantly. That means more people will qualify for a mental illness diagnosis—which leads to more medication and more stigma for what’s often temporary, and even normal, human distress. By eliminating the bereavement exclusion from DSM-4, we’d be increasing the number of people diagnosed with depression. And the new diagnosis of “attenuated psychosis syndrome” will label some people “at risk for psychosis” when they are not psychotic. This will likely expand the number of people prescribed antipsychotic drugs. Also, for both attention deficit hyperactivity disorder (ADHD) and generalized anxiety disorder, there has been a lowering and loosening of diagnostic criteria, and this too will result in more drug prescribing.
Just as worrisome, the coalition has concerns about DSM-5’s subtle changes to the definition of what constitutes a mental disorder. These changes may, say the coalition, “result in the labeling of sociopolitical deviance as mental disorder.” The coalition concludes that this change, as well as changes to categories within the manual, will result in less focus on the social and political roots for mental suffering, and even more focus on biochemistry—which will result in more medication. This new focus is disappointing but not surprising, since as the journal PLOS Medicine reported in 2012, “69 percent of the DSM-5 task force members report having ties to the pharmaceutical industry.”
What do you think about the new DSM-5 and these changes? Do you think it'll lead to more people being diagnosed as mentally ill—and more medication?
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Bruce E. Levine, Ph.D,. is a practicing clinical psychologist who writes and speaks on how society, culture, politics, and psychology intersect. His latest book is Get Up, Stand Up. Earlier books include Surviving America’s Depression Epidemic and Commonsense Rebellion. TakePart.com