The long-awaited, controversial new edition of the bible of psychiatry can be characterized by many numbers: its 947 pages, its $199 price tag, its more than 300 maladies (from "dependent personality disorder" and "voyeuristic disorder" to "delayed ejaculation," "kleptomania" and "intermittent explosive disorder"), each limning the potential woes of being human.
But to the psychiatrist who shepherded the tortuous creation of the Diagnostic and Statistical Manual of Mental Disorders, perhaps the single most important number is the "5" in its title: This is the DSM-5, not the DSM-V.
That may seem like a cosmetic change, but the American Psychiatric Association, which released the book on Saturday at its annual meeting, decided to use Arabic instead of Roman numerals because "we want it to be a living document," said Dr. David Kupfer of the University of Pittsburgh, the chairman of the task force that produced the DSM-5. Rather than waiting another generation to revise the manual—the DSM-IV was published in 1994—psychiatrists will regularly update it with, for example, findings from genetics and neuroscience, labeling the revisions DSM-5.1 and DSM-5.2 and so on.
"We used '5' because V.0 and V.1 just don't look good," said Kupfer.
The fact that the world's most powerful psychiatrists (their decisions determine what counts as a mental disorder, and thus what insurers cover and which children receive special services in school) are already building in ways to change the manual is commendable, even its critics say.
But it is also emblematic of the DSM-5's failures, they argue, which include turning normal human behavior and feelings into mental illnesses, and expanding the criteria for disorders until an astonishing one in four U.S. adults has a diagnosable mental illness every year—and even more do over a lifetime.
The latest revision began in 1999 with high hopes for putting mental illness on a scientific footing, using neuroscience in particular to tell the difference between, say, normal sadness and major depression.
That reflected persistent criticism that "drawing a line between sickness and disease is a special problem in psychiatry," said psychotherapist Gary Greenberg, who participated in the "field trials" that tested the DSM-5's proposed diagnostic criteria before they made the final cut. "We don't have blood tests or other objective criteria to distinguish mental sickness from health. So you have a set of criteria that are very common, which means the potential for many people being diagnosed as mentally ill when they're not."
One of the more controversial changes was to eliminate the previous DSM's "bereavement exclusion" for depression. Now, if a father grieves for a murdered child for more than a couple of weeks, he is mentally ill.
STILL WAITING FOR SCIENCE
The 1,500 experts who contributed to the DSM-5 would have liked nothing better than to base diagnoses on genetics or neuroscience, rather than on subjective judgment and lists of mostly self-reported symptoms such as fear of acting "in a way that will be negatively evaluated" (social anxiety disorder) or approaching and interacting "with unfamiliar adults" (disinhibited social engagement disorder in children).
"It would be great if we had been able to have a paradigmatic shift" by basing the diagnosis of mental illness on biology, as the APA hoped to when it began the DSM-5 process, said Dr. Jeffrey Lieberman, chairman of psychiatry at Columbia University and president-elect of the APA.
But the science did not arrive in time. "The DSM can only reflect the research we have," said Lieberman." With rare exceptions such as narcolepsy, which can be diagnosed by testing cerebrospinal fluid, there are no objective biological measures for mental illness.
This lack of scientific rigor led the nation's leading mental health official to attack the DSM-5 for a "lack of validity," as Dr. Thomas Insel, director of the National Institute of Mental Health, said in a blog post late last month. The manual bases diagnoses on symptoms, he noted, but "symptoms alone rarely indicate the best choice of treatment." Allergies and flu share some symptoms, for instance, but no doctor would try to treat flu with an antihistamine.
"Patients with mental disorders deserve better," said Insel, who announced that "NIMH will be re-orienting its research away from DSM categories."
Pittsburgh's Kupfer shrugged off this attack. "NIMH expressed that a couple of years ago," he said. "It would be a mistake to reify the DSM for research purposes."
"Reification" has become a buzzword among the DSM's critics. In this context, it means "taking a concept and turning it into a reality," said Greenberg, whose new book, The Book of Woe: The DSM and the Unmaking of Psychiatry argues that the manual and the process behind it are hopelessly and dangerously flawed. "The categories are not reliable in a biological sense."
That can cause harm to people who are labeled "mentally ill" when all they have is a variation of normal human behavior, said Greenberg. "The sphere of normality has to have room for some distress, which is part of being human."
On a practical level, "once you have a diagnosis in your medical record you can have trouble getting insurance or a security clearance, and it changes how you think of yourself," said Greenberg.
Changes that make it easier to qualify as mentally ill—fewer symptoms, lasting for a shorter time—have drawn the most impassioned criticism of the DSM-5. Dr Allen Frances, the psychiatrist who led the development of the last DSM and who has emerged as the new one's fiercest and most eminent critic, warns of a "hyperinflation" of diagnoses and calls for "a black-box warning" in the dozen or so most controversial changes, much like the black-box warning that regulators require on the labels of potentially dangerous drugs.
The black box, he said in a 2012 essay, would indicate the risks of calling people who engage in binge eating, for instance, or who grieve a dead child mentally ill, and would serve as "an admission that the change is a hypothesis," not a scientific fact.
The new DSM does not include more disorders than its predecessor, said Lieberman, "and it shouldn't increase the number of people who warrant a diagnosis of mental illness." The changes it does make, however, could have far-reaching consequences.
It classifies compulsive gambling as an addiction, the first behavior to be so categorized. That could make it easier for pathological gamblers to get help, said Jeff Beck of the New Jersey Council on Compulsive Gambling and a recovering gambling addict.
The new manual also breaks out compulsive hoarding from obsessive-compulsive disorder and makes it a stand-alone disorder. That should tell clinicians that treatments that work in OCD are not the best way to treat hoarders, said psychologist Randy Frost of Smith College, who has developed a unique therapy for hoarding.
One of the more controversial changes was to eliminate the previous DSM's "bereavement exclusion" for depression. Now, if a father grieves for a murdered child for more than a couple of weeks, he is mentally ill. A footnote in the DSM-5 explains that "the inability to anticipate happiness or pleasure" in such a situation is a diagnostic criterion for the mental disorder of depression.
To some, this smacks of pathologizing a normal, understandable human reaction. "This completely leaves the person out of the equation and turns people into patients," said psychotherapist Eric Maisel, a critic of the DSM. "The DSM claims that an unwanted, distressing feeling is a sign of a disorder rather than being just a feeling, and it isn't at all interested in whether your circumstances could have caused those feelings."
It is important to consider circumstances, he said, because if someone experiences deep anxiety as a result of losing her job, becoming ill or facing foreclosure, "the remedy shouldn't be a pill," the usual outcome of a diagnosis of "generalized anxiety disorder."
The DSM-5 will likely reduce diagnoses of autism spectrum disorders (ASD). It eliminated Asperger's syndrome and tightened the ASD criteria.
While no one wants to see children incorrectly labeled, said Katie Weisman of the patient advocacy group Safe Minds, "children who were borderline cases under the previous DSM now won't get a diagnosis, which means they won't be eligible" for early, intensive behavior therapy—or won't have it paid for by insurance. A mother of triplets on the autism spectrum, Weisman says "I'm not sure my boys would be where they are today"—in regular school classrooms, not special education—"without these services."
Whether the critics' fears come true will become clear only once psychiatrists, psychologists, and even primary-care providers—who write the majority of prescriptions for drugs to treat mental illness—begin using the new DSM. "We're trying to establish accurate and reliable guidelines, and you can't completely control how they're applied," said Columbia's Lieberman. "The problem is not with the instrument but with the way it's used."