This article is part of Next, The Globe's five-day series examining the people, places, things and ideas that will shape 2013.
The latest revision of the Diagnostic and Statistical Manual of Mental Disorders, the most current attempt to catalogue humanity’s moods and mania, confirms one thing: Diagnosing the trials of the mind is still more art than science. It’s vulnerable to both trends and politics. The field’s brightest experts bicker, and the patrons, Big Pharma, have their own agenda.
When it’s published in May, the DSM-V will become the new textbook for mental-health professionals, influencing everything from workers’ compensation claims to research, and, perhaps most significantly, how and when medication is prescribed. The DSM is published by the American Psychiatric Association, but has international sway with mental-health practitioners. It identifies emerging areas of study, defines new disorders, and updates the definitions of core mental illnessessuch as depression and anxiety. Its contents are already forcing questions about society’s ever-shifting definition of “normal,” with the number of diagnoses increasing.
“Billions of dollars are riding on these decisions,” says medical historian Ed Shorter, at the University of Toronto. “It’s very important in the real world which diagnoses get in, and which ones get taken out.”
Critics have decried the final draft as “hopelessly flawed, warning it may lead to unnecessary treatments. The best that most of its defenders can say is that it’s a sound, if imperfect, compromise. To illustrate the delicate – and, many argue, dysfunctional – balancing act, here are a few high-profile examples among the many revisions expected when the DSM-V comes out next spring:
When a revision of the DSM-IV in 2000 made Asperger’s, a disorder on the mild end of the autism spectrum characterized by behavioural symptoms, a separate disorder, it launched a wave of research in the area. The new version of the DSM moves Asperger’s back under the umbrella of Autism Spectrum Disorders. The DSM panel estimates that 10 per cent of patients may no longer qualify for a diagnosis, but the real effect is hard to predict. (Asperger’s is also one of the few examples of a revision that narrows a diagnosis rather than expands it.)
Dr. Pippa Moss, a child psychiatrist with the Cumberland Health authority in Nova Scotia, who also has a child with autism, says the decision is based on the science that the previous DSM definition fostered. “If a diagnosis is going to be useful, it needs to tell you something unique about treatment or support,” Dr. Moss says. Not only do children tend to drift over their lifetime between the symptoms of Asperger’s and high-functioning autism, especially during stressful periods, the therapies are similar. Basically, making Asperger’s a distinct disorder in 2000 helped researchers study it enough to conclude that it didn’t need to be one.
The decision has prompted an outcry from powerful family lobby groups, who worry about the impact of school resources, and that some children, who need support, may now fall outside of the diagnosis. (The DSM clarifies that patients who now have the diagnosis will not lose it.) The diagnosis of Asperger’s, with its positive association with bright, eccentric adults and prodigies, is a good example of the power of language in psychiatry. Parents would rather be told their child has Asperger’s than high-functioning autism, even if there isn’t a science-based difference.
The DSM is crafted largely by U.S. doctors trying to strike a tricky balance between not missing patients, and not catching too many. Some outspoken critics, such as Allen Frances, a Duke University psychiatrist who chaired the DSM-4 task force, argue that the manual keeps expanding, often without clear supporting science. The number of people diagnosed under these new or widened disorders is almost always higher than field trials predict. “Psychiatry is subject to fads,” he says, “and very small changes can have huge unintended consequences.”
For example, the new DSM removes the “bereavement exclusion,” which previously restricted psychiatrists from diagnosing depression in patients who were grieving. But some feared that people with clinical depression weren’t getting help.
But expanding the definitions of mental-health conditions has been a worrisome trend for many experts, especially as the use of anti-anxiety drugs and anti-depressants has skyrocketed. In psychiatry, the line between function and dysfunction are, after a certain point, subjective for both patient and practitioner. When does sadness become depression? Or worry slide into anxiety? The most important measuring stick is distress: When someone can’t live with their symptoms, it becomes a mental-health issue. Removing the grief exclusion is designed to allow psychiatrists to make that assessment as the situation warrants. In the end, the DSM authors compromised and included a note that reminds practitioners to consider that a tragic event could cause “depressive symptoms,” but not clinical depression.