The mind, in our modern conception, is an array of circuits we can manipulate with chemicals to ease, if not cure, depression, anxiety and other disorders. Drugs like Prozac have transformed how we respond to mental illness. But while this revolution has reshaped treatments, it hasn't done much to help us diagnose what's wrong to begin with. Instead of ordering lab tests, psychiatrists usually have to size up people using subjective descriptions of the healthy vs. the afflicted.
Which is why the revision of a single book is roiling the world of mental health, pitting psychiatrists against one another in bitter debates. The book is the Diagnostic and Statistical Manual of Mental Disorders, or DSM for short, and it is the bible of mental illness. First published in 1952, the DSM attempts to catalog every psychological problem humans experience. The new edition set to be published next year will be the first revision since 2000. It will literally redefine what's normal.
On any given day, 4.4 million Americans receive mental-health services. Patients, doctors, insurers, pharmaceutical companies and taxpayers all have a stake in how the new edition is written. For anyone feeling down or anxious, tweaks to the DSM may determine whether their symptoms are merely unpleasant or actually signs of disease. These changes will ripple through the mental-health field and affect whether and how much insurers will pay for treatment. Small wonder, then, that the production of what's being called DSM 5 is wildly controversial.
Some of the most heated disputes revolve around how to diagnose well-known disorders. DSM contributors have proposed rewriting the definitions of autism, depression and schizophrenia, among others. Autism would become part of a "spectrum" of disorders including milder social-interaction problems like Asperger's syndrome. That proposal has angered advocates for the autistic, who fear the changes could obscure the reality that some autism patients need lifetime supervision. The new definition of depression would eliminate a current exception for bereavement, meaning those mourning the loss of a loved one could be diagnosed with an illness. The American Psychiatric Association (APA) has proposed adding binge-eating disorder, though it would be defined, in part, with an imprecision bordering on absurdity: eating "an amount of food that is definitely larger than most people would eat."
Even as these arguments rage, science is making progress in unraveling what makes the mind go awry. Magnetic-imaging technology has shown that, for instance, when we are scared and anxious, the neurons in a brain region called the amygdala light up. But clinically speaking, when a patient is in front of a desk, that knowledge matters little in whether a psychiatrist can diagnose anxiety disorder. Dr. David Kupfer, the genial University of Pittsburgh professor who chairs the DSM revision, says that although genetics and neuroscience have offered powerful insights into how mental illness begins, the research hasn't advanced enough for use as a diagnostic tool. "I can't do neuroimaging in my office," he says. "We are lacking the validation of these methods, which are promising but not decisive." In simpler terms, mental-health diagnosis remains as much art as science.
A Guidebook for the Mind
To understand the importance of the DSM, you have to go back to 1840, when the U.S. first asked in the Census about the frequency of "idiocy/insanity." Those who ran asylums had no standardized way to diagnose patients, which meant their treatments were capricious and occasionally abusive.
In 1917, a group of U.S. psychiatrists persuaded the Census Bureau to gather uniform statistics from mental hospitals. What resulted was a mental-illness section of the American Medical Association's Standard Classified Nomenclature of Disease, which guided psychiatrists in how symptoms clustered to form illnesses. From the beginning, what became the stand-alone book known as the DSM was controversial. The editions published in 1952 and 1980 deepened divisions between Freudians and their rivals, behavior therapists who had absorbed the ideas of Harvard's B.F. Skinner, who believed psychology should be grounded in clinical trials rather than therapy sessions with no definable end points.
All the debates originate from a central problem: we know the basic biology behind, say, leukemia, but we are mostly guessing at the biology of, say, obsessive-compulsive disorder (OCD). For all the magnetic-resonance-imaging tests that tell us which parts of the brain activate during obsessive-compulsive episodes, we are far from a blood test that could separate those with OCD from those who scrub their pots to a gloss when a mere rinse would do.
Over the years, the gray areas have allowed many forces beyond science to shape the DSM, including politics. In 1974, the APA actually held a vote among members to determine whether one alleged disorder–homosexuality–even exists. Being gay was deemed sane by a vote of 5,854 to 3,810, and homosexuality did not appear in the third edition of the DSM, published in 1980.
A Paradigm Shift
In the late '90s, when dsm 5 research began, the success of Prozac and other new drugs led many psychiatrists to believe they might be able to abandon the old diagnostic approach–depression is an abnormal or unconscious reaction to sad situations–for a chemical explanation: depression is a misfiring of neurotransmitters. Many researchers thought psychiatry was on the verge of identifying underlying disease processes–that DSM 5 could codify a paradigm shift, tilting more heavily toward science and away from art.
It didn't turn out that way.
As Columbia University psychiatrist Michael First–an editor of the fourth edition of the DSM–wrote in the November 2010 edition of the Canadian Journal of Psychiatry, "not one single laboratory marker has been shown to be diagnostically useful for making any DSM diagnosis." True, genetic testing can predict a small number of neuropsychological illnesses like Rett's disorder (the emergence of serious movement problems in early childhood). But as for widespread illnesses such as depression or anxiety, multiple studies of twins in the '00s failed to find a distinct genetic basis. And so, as First writes, the core question for clinicians–"whether or not to treat"–won't get much easier after the new book appears.
What DSM 5 almost certainly will do is help APA members bill insurance companies for more conditions. Kupfer told me he won the position of editing the DSM 5 on a platform of not adding more disorders unless they are supported by rigorous, peer-reviewed studies. But many of the APA's 36,000 members are pushing for new diagnoses–not just binge eating and Internet addiction but dubious conditions such as premenstrual dysmorphic syndrome (psychological problems that occur before a menstrual cycle) and female orgasmic disorder (the inability of women in stable relationships to climax).
The threat of diagnostic inflation has occupied hours of debate at DSM 5 conferences, and many mental-health professionals have disputed the new proposals. The APA has received more than 10,000 comments–many of them acrid–on its website. The most serious challenges have come from the head of the DSM's third edition, Dr. Robert Spitzer of Columbia University, and from Dr. Allen Frances, who chaired the team that edited the fourth edition. Both have suggested that DSM 5 will lead to the pathologization of ordinary behaviors such as sadness over a spouse's death and occasional overeating. Spitzer, Frances and others have also criticized the APA for requiring the hundreds of psychologists and psychiatrists contributing to the book to sign nondisclosure agreements preventing them from revealing any text before the official DSM 5 publication, scheduled for May 2013. "It just goes against fundamental science," says Allan Horwitz, a Rutgers University professor and expert on the DSM. "Science should be subject to critique and revision."
The APA, a nonprofit that has earned millions of dollars from worldwide sales of the DSM, is firing back. Kupfer says the nondisclosure agreements are a standard part of academic publishing. "No one reveals results before publication," he says. In June the APA hired a former Pentagon spokesman, James Tyll, to help defend the new version. Tyll says the new DSM is backed by thousands of hours of research and meticulous peer review. He told me that Frances is a "dangerous" man trying to undermine an earnest academic endeavor. Frances has fought icy allegations that he is worried about losing royalties and prestige after his version of the book goes out of publication. Frances has said his royalties amount to just a few thousand dollars and that his critiques are purely academic.
The acidity of the debate has shocked the academic world. "It's odd for us," says one of the 13 DSM task-force leaders, a longtime researcher who requested anonymity because of the politics around the DSM revision. "But you shouldn't lose sight of the fact that we are working on how neuroscience has advanced to improve the diagnosis of mental illnesses. This book will change, for the better, how everyone in this field works." In short, those behind current DSM science hate DSM politics.
The DSM will remain powerful because clinicians, hospitals and regulators need a lingua franca. Even if the manual doesn't offer the dramatic new paradigm that psychiatrists hoped for when DSM 5 research began, the elusive promises of neuroscience and genetics could be realized in a later edition of the book. A few years after DSM 5 appears, research on DSM 6 will begin. And the arguments will start all over again.