DSM-5: the branding of mental illness

It is fitting that my first blog post roughly coincides with the recent certification by the board of trustees for the American Psychiatric Association on the new diagnostic categories for the DSM-5.  Several years ago, I wrote a highly controversial article entitled The Art of Branding a Condition, which detailed how pharmaceutical companies have helped shape the discussion around treatment by driving new perceptions about pathology.  Namely, how does one re-classify a series of behaviors, symptoms or poorly understood diseases into a commonly recognized, treatable condition?  (Think Restless Leg Syndrome.)  Such is the intention of the DSM, though many would argue that nefarious motives have hijacked that intention.

Without a blood test or a biopsy or any yardstick whatsoever, how is anyone able to scientifically determine where the line is that distinguishes normal human behavior from a mental illness—a crank from someone with Major Depressive Disorder, an absent-minded aunt from one with Minor Neurocognitive Disorder, a gluttonous pig from someone who suffers from Binge Eating Disorder?  These are all newly identified diagnostic categories to be found in DSM-5, arriving in bookstores this May. The problem really comes down to this: there’s nothing scientific about it.  True, the process for designating such parameters is achieved by convening All the Shrinks’ Horses and All the Shrinks’ Men—a who’s who of psychiatric and behavioral experts—to evaluate the literature, trends, beliefs and practices since the last edition in 1994 and update the manual.  But that’s less of a science than it is a best-guess endeavor—the equivalent of, say, Rolling Stone magazine publishing the Top 100 guitar players of all time.  Some will shout Righteous!  Some will shout, What, No Buck Dharma?  But all will shout, loudly, because there are no right answers to be found, just literate, informed opinions.

Admittedly, the Top 100 guitarists analogy may piss off a legion of metal heads, classists and, well, just plain old heads, but it can’t really do any real damage.  Not the case for DSM-5.  Look what hangs in the balance: without a bona fide condition, patients don’t get reimbursed for treatment; without a consensus on the disorder, there’s no standard of care, so many with a mental illness won’t get treatment and many normal people will; without an attempt to classify what is normal and what is pathological, the whole enterprise of mental health becomes anarchy.

I will leave it to the learned medical experts, such as Allen Frances, chairman of the DSM-4 task force, to debate whether or not Disruptive Mood Dysregulation Disorder (excessive temper tantrums), or Gender Dysphoria (feeling like you were born the wrong sex, a.k.a Chaz Bono syndrome) are “changes that seem clearly unsafe and scientifically unsound.”  This, to me, comes down to a classic case of branding envy—or, to recall Mark Twain’s comical example in his short fictions, Adam and Eve’s Diary, who gets to name the animals? (Eve takes charge and stirs Adam’s ire.)  Psychological experts and medical opinion leaders are like any other public figures trying to raise their profiles.  If you can give a condition a name and that name sticks, then you own it, you’ve branded it.  Dr. Frances calls some of the new diagnostic categories “fad diagnosis” and “pet ideas” (there’s that animal thing again), but in doing so, he’s engaging in trying to re-brand others’ thinking as trivial, dangerous and vain.

I will, like Dr. Frances, applaud the initiative that is DSM-5.  It may be more of a guideline than a bible, as he argues, but without guidelines we’d be lost.  Branding conditions of mental health is a noble enterprise.  It helps patients realize that they may be able to get help for a formerly un-identified syndrome; it removes the stigma associated with socially embarrassing behaviors; it gives doctors expanded knowledge to help more of their patients; and it shines light a little further into the darkness that is the human mind.  The trustees who approved the criteria in DSM-5 may not have gotten everything “right,” but they did the dirty work that had to be done.  They shouldn’t regret their efforts.  They shouldn’t mourn lost opportunities.  They should hold their heads high, feel proud, and not exhibit any form of Remorse Spectrum Disorder.  (I made this last one up.  Look for it in DSM-6!)

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