Surface Appearances – DSM-V: Small Changes, Unintended Consequences?

What had struck me was the neat appearance of the guillotine; its shining surfaces and finish reminded me of some laboratory instrument. One always has exaggerated ideas about what one doesn’t know. Now I had to admit it seemed a very simple process, getting guillotined […] as it was, the machine dominated everything; they killed you discreetly, with a hint of shame and much efficiency. Albert Camus

You may or may not know, but this Saturday the newest version of the psychiatric Bible (the DSM-V) will “finally” be released. Being the most influential tool so far for classifying, diagnosing and treating mental disorders, the US manual doesn’t make everyone equally happy. As UK-based newspaper The Guardian wrote this morning:

Early drafts of the book, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, have divided medical opinion so firmly that authors of previous editions are among the most prominent critics.

And they are absolutely right. About a year ago, while I was researching on precisely this topic for one of my philosophy papers, I came across an article written by Allen Frances (one of said authors) in March 2010 for the Los Angeles Times, poignantly titled It’s not too late to save ‘normal’. Frances who himself was “chairman of the task force that created the [then] current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which came out in 1994” tells us how he had to “learn from painful experience how small changes in the definition of mental disorders can create huge, unintended consequences”.

Picture taken from The Wall Street Journal

Where the DSM-versus-normality boundary is drawn also influences insurance coverage, eligibility for disability and services, and legal status — to say nothing of stigma and the individual’s sense of personal control and responsibility. Allen Frances

So, next to the fact that grief now qualifies as a major depressive disorder (as if that wasn’t bad enough), the real problem fully arises when one looks at the way in which mental disorders are classified in the DSM-V. We are not really dealing with scientific evidence, instead the classification of mental disorders is largely based on observed clusters of symptoms. Or, to let Thomas Insel speak:

Unlike our definitions of ischaemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.

John Horgan wrote about Insel only recently for the Scientific American, with the (somewhat funny) title Psychiatry in Crisis! Mental Health Director Rejects Psychiatric “Bible” and Replaces with… Nothing. Simply put, Insel wants to research mental disorders free from DSM categories, in order to find evidence “based not just on vague symptomology but on more specific genetic, neural and cognitive data”.

Seems nice enough, there’s only one problem: this will take a long time and success isn’t guaranteed. Specifically, since Insel tells us in the same go that “we cannot design a system based on biomarkers or cognitive performance because we lack the data”. I can only agree with Horgan’s conclusion that, if nothing else, this war between deeply flawed DSM categories and a severe lack of useful empirical data, shows that “modern psychiatry is in a profound state of crisis”.

Moreover, until such time where Insel’s dream of a better developed RDoC (Research Domain Criteria) project for psychiatric diagnoses becomes a real possibility, the DSM will likely continue to dominate our interpretations of ‘mental sanity’. And as if psychological mumbo-jumbo wasn’t sufficiently present in our vocabulary just yet, now we can’t even grieve our loved ones anymore without the fear of being labeled “majorly depressed”. How can it be a disorder to have loved and lost, and actually feel that loss for a while? When did we run out of time to contemplate, go into and even lose ourselves – in order to find new ways to be? And when exactly did it become oh so clear what ‘normal’ is, anyway? As Allen nicely puts it in his aforementioned article:

Defining the elusive line between mental disorder and normality is not simply a scientific question that can be left in the hands of the experts

People have a right to feel, and we must be very careful with so-called “laboratory produced” manuals that supposedly know how to divide us all into “normals” and “not-normals”. Just like the guillotine for Camus – a neat appearance and a shiny surface, a sterile laboratory instrument, something that appears so small and unhazardous before our eyes doesn’t prove its innocence simply by the way it looks. After all the negative things we’ve heard of the DSM-V so far, we may easily imagine it as some kind of dangerous trap, lurking over our minds, designed to capture anyone who gets too close.

Taken from Labor Related

… but in the end, it’s just a book. Right? Are we really just exaggerating in our minds what we do not yet understand? No, it really never depends quite so much on the way things look – the real puzzling part is how, when and why they could become weapons and whose heads will be figuratively decapitated first when they do.

Classificatory thought gives itself an essential space, which it proceeds to efface at each moment. Disease exists only in that space, since that space constitutes it as nature; and yet it always appears rather out of phase in relation to that space, because it is manifested in a real patient, beneath the observing eye of a forearmed doctor. Michel Foucault


3 thoughts on “Surface Appearances – DSM-V: Small Changes, Unintended Consequences?

  1. Pingback: New US manual for diagnosing mental disorders published | DSM-5 | | lennyesq

  2. The Camus quote is so fitting! Ha, ha!

    Dr Kay Redfield Jamison, a prolific writer on psychiatry, has tried to distinguish grief from major depression. If you’d like to check it out it’s

    I also found a very amusing TED Talk on mental diagnosis, specifically psychopathy. Though, I think what this fellow says applies to clinical psychology in general as well. I think you’d like it.

    • Hey there! Sorry, due to cirucmstances I’ve been inactive for a while. But I will definitely take a look at your links, coming from you, I’m pretty certain they will be interesting. Thanks a lot 🙂

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