The experience is so profound that the American Psychiatric Association’s proposal to recast grief as mental illness in the revised Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which will be released next month for use around the world, has jarred a great many people, both lay and professional. So have several other revisions, to definitions of anxiety, behavioural addictions, even how we navigate physical pain.
It is a peculiar and reductive logic about the nature of being human, this idea that grief – or stress, or bingeing on pie – merits medical intervention. And it is a logic that pervades the DSM revisions, which is why the manual is proving wildly controversial on the eve of its unveiling.
Psychiatrists have resigned from the revision working groups to protest against various criteria; open letters have been penned by the British Psychological Society, and the American Society for Humanistic Psychology; petitions have been signed by thousands of mental-health practitioners; boycotts are being planned in both North America and Europe. “I will not buy DSM-5. I will not use it. I will not teach it,” psychiatrist Patrick Landman, of Université de Paris VII, declared in Psychology Today, where several professionals have taken to voicing their fierce opposition with ongoing blogs.
The original edition was published in 1952 in order to standardize diagnostic criteria, reflecting at the outset the optimistic notion that our social and emotional lives might be tidily catalogued. Subsequent revisions have manifest the fashions of the times. Homosexuality was in at one point. Then that came out, and shyness went in. What is fashionable now, it seemsfor all intents and purposes, is expanded catchment.
This is the overriding concern of mental health professionals who oppose the DSM-5. As the manual grows (the original had 95 mental disorders; the last edition, 283), they argue that it lowers so many thresholds for being diagnosed with minor mental illnesses that life, itself, becomes treatable as disease.
The proposed revisions to Generalized Anxiety Disorder, for instance, drop the bar practically to the level of being worried about your job and having muscle tension. You need to have one of four symptoms, according to psychiatrists who have seen the draft, and be worrying “excessively” about at least two areas of your life. Your job and your finances, say. How worried is too worried? What is wrong with waves of dread when your bank account dwindles to zero?
Allen Frances, a U.S. psychiatrist and professor emeritus at Duke University who oversaw the previous DSM revisions in 1994, calls this “a travesty of careless suggestions that will likely turn our current diagnostic inflation into hyperinflation.”
One of the most decried DSM revisions involves the introduction of “Somatic Symptom Disorder,” which will be diagnosed in a patient who displays “excessive and disproportionate thoughts, feelings and behaviours” in relation to an illness. It doesn’t have to be an imagined illness, or a medically unexplained illness. It can be cancer, or gout. If you are plagued by chronic pain, let us say, and fret about it a lot, then your physician can decide that you are being unreasonable, and thus declare you disordered.
Of course, clinicians do not have to make such diagnoses. For example, there’s no imperative to diagnose people with “Major Depressive Disorder” if they are grieving. But in the DSM-5, the APA removes the exemption of mourning from a diagnosis of mental illness because there are no biological markers to distinguish the two states. You cannot rule out one or the other on the basis of a blood test, or a brain scan. Therefore, members of the APA have argued, the bereaved deserve access to the same treatment as everyone else.