The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders. The DSM is sometimes referred as “the therapist’s Bible.” The DSM has enormous on who will and will not be called mentally ill and what the varieties of mental illness will be.
The leading therapists often disagree about which label to assign to a given patient, and there is less definitive research than one might expect to prove that “A person with diagnosis X will benefit from and not be harmed by treatment Y.” As such, each generation of DSM emerges with some controversy. This was true for the DSM (in 1952), then DSM-II (1968), DSM-III (1980), DSM-III-R (Third Edition Revised) (1987), DSM-IV (1994), and DSM-IV-TR (2000).
As the DSM-5 is being drafted on the heels of the promise of a “paradigm shift,” a debate has been ignited, fueled by the likes of old-guard DSM architects Drs. Robert Spitzer, MD, and Allen Frances MD, on the one hand, and current DSM-5 framers lead by David J. Kupfer, M.D., who are forging relentlessly onward toward a 2013 deadline on the other. The debate has many facets involving both content and process, but at the center is "what constitutes a mental illness and what are the appropriate targets of psychiatric intervention".
Do 44 million people in the USA have a mental disorder?
Or does the DSM encourage an overstatement of mental illnesses? BPDFamily.com reported in November 2010 that the US Surgeon General estimates that 28% of the US population suffer from either a mental or addictive disorder in a given year. This is based on the DSM-IV. The current prevalence estimate is that about 20 percent of the U.S. population are affected by mental disorders during a given year. This estimate comes from two epidemiologic surveys: the Epidemiologic Catchment Area (ECA) study of the early 1980s and the National Comorbidity Survey (NCS) of the early 1990s. Those surveys defined mental illness according to the prevailing editions of the Diagnostic and Statistical Manual of Mental Disorders. The surveys estimate that during a 1-year period, 22 to 23 percent of the U.S. adult population.
DSM IV increased the number of mental illness categories by 25%
DSM-III-R contained 297 categories and DSM-IV contained 374. Each time a new edition appears, the media ask whichever psychiatrist is the lead editor why a new edition was necessary, each editor replies that it was because the previous edition really wasn’t scientific (Caplan, 1995). And each time a new edition appears, it contains many more categories than does the previous one.
Are the findings of the DSM 5 premature?
Dr. Frances cautions how the inclusion of spectral views of mental disorder in DSM-5 could contribute to inappropriate medicalization of “problems of daily living” and the sanctioning of pharmacologic interventions for conditions where evidence-based practice does not yet exist (e.g. indiscriminate use of antipsychotics for the “psychosis risk syndrome”).
At the same time, Frances states "for many domains of psychopathology, a spectral view does reflect biological reality and that etiologic discoveries do require a shift to dimensional models of mental illness. However, DSM-V doesn’t need to exist for a dimensional approach to research to take place—such inquiry has already been ongoing for years. In fact, I would argue that DSM revisions should follow this kind of research rather than the other way around. Yet it seems that the move towards dimensionalization in DSM-V has already begun and that an immediate impact on clinical practice is inevitable.
It is within arenas in which categorical judgments about mental pathology are both essential and have significant and potentially harmful consequences—the aspects of clinical intervention described above as well as with the various “third parties” that use DSM (e.g. governments deciding resource allocation, insurance companies reimbursing for care, the legal system making decisions about moral responsibility)—that thoughtful decisions must be made about how best to adapt to a spectral view of mental illness. It is therefore our collective destiny that ethical discussions about what could occur will soon become practical discussions about what does occur."
Defining mental illness is complicated - where do you draw the line?
One prominent DSM-IV author has proposed that “relational disorder” be added to the manual. “Relational disorder” would be applied to a couple, neither of whom individually might be considered mentally ill but whose relationship would be considered sick. It is revealing to picture this scene: Two people sit in a psychiatrist’s office; neither of them is considered mentally ill, though their relationship is; the psychiatrist removes a pill from its bottle…where does the psychiatrist put the pill?
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