This month the American Psychiatric Association will publish its fifth edition of the Diagnostic and Statistical Manual. This publication has been met with criticism and skepticism, much of it covered on this website.
As the medical director of a community mental health center, my colleagues look to me for guidance on how to approach this new edition. How many should we buy? How much time should be devoted to staff training? Although this is a book published by psychiatrists, it has become widely used as the basis for diagnosis by many clinicians.
I have written previously about what psychiatric diagnosis does and does not tell us. I am well aware of the many limitations of labeling something about which we have such limited understanding. As widely publicized, Thomas Insel, the Director of the National Institute of Mental Health published an essay on the eve of the publication of DSM-5 which essentially laid out the profound limitation of this guide.
People on this particular website may deride any service offered in a community mental health center like the one which employs me, but everyday people come to us seeking help. We are embedded in the social service network and the insurance system. This is all reliant on some sort of process to allow us the get paid for our services. That process is based on diagnosis. The scope of the need goes far beyond seeing a psychiatrist. If someone is homeless and needs a voucher for a hotel, if someone needs a coach to help find a job, if someone wants help to stop abusing alcohol, if that person and his therapist agree to check urine samples to follow his progress, all of this requires someone – often me – to provide a diagnosis.
When I think about replacing this model, I have wondered whether it might be helpful to allow each citizen to draw from a fund at any point in her life without regard to a faulty diagnostic system. If a young person hits a rough patch where she seems unable to focus and has trouble staying at work, she could draw on this for a period of time until she rights herself without out having someone apply a label based on a system that so many people agree is flawed and lacking in validity. Another person might rely on this when a loved one was ill and needed care. This might raise the bar for requiring us to label a person as disabled or anything other than someone who for whatever reason needs a time out.
That is a thought. Probably not a realistic one. So what do I do in my own world now? My answer to my colleagues is to wait. I do not believe the DSM-5 is anything other than a code book. I think we will be able to find out for free how the codes have been adjusted and changed. We can look at the ICD system which is available on line. We have limited resources and it does not appear to me that they are well used in buying this book or retraining our staff.
Most importantly, we need to train our staff and talk to the people we serve about what these labels do not tell us. They do not answer what is wrong or what happened in a person’s life. These labels do not tell us who can recover. Even for those who believe that the drugs we prescribe may be helpful, the labels do not tell us much about what specific drug will be effective. So-called antidepressants, for instance, are used so broadly that the label makes little sense. Even for those who believe that we will understand extreme states by deconstructing the fundamental workings of the brain, these labels do not inform us about brain function or dysfunction.
On a positive note, perhaps the publication of the DSM-5 has prompted a much-needed discussion of the profound limitations of psychiatric diagnosis.