"Just tell me the first thing that comes to mind," the doctor instructs the patient as he shows him the ink blots.
"Sex," answers the patient.
"I see," says the doctor. "And this one?"
"And this one?"
"Well," says the doctor, "I see we will have to work on your obsession with sex."
"Me??" replies the patient. "You're the one with the dirty pictures!"
What I love about this joke is that it gets right to the subjectivity of psychiatric diagnosis, a problem that has plagued the field since its infancy in the late 19th century and probably always will. We can now confidently diagnose cancers, infectious diseases, and other conditions based on data: biopsy results, lab tests, and X-ray images. But it seems unlikely that even the most advanced understanding of how the brain functions will ever fully elucidate how the mind dysfunctions.
Still, people do suffer from mental illness, and the American Psychiatric Association (APA) has tried, since 1952, to delineate an orderly system of diagnosis by producing a catalogue called the Diagnostic and Statistical Manual of Mental Disorders. For decades, every medical student purchased one in a series of revisions of the "DSM." Mine was DSM III, which--even if I wanted to lie about my age--places me firmly in the 1980s. The book contains descriptions of dozens of disorders, from schizophrenia to borderline personality to binge eating disorder, each with a menu-style selection of symptoms. Here, for example, is the DSM IV criteria for major depression:
Though this system of diagnosis may seem primitive, it's been felt a superior alternative to no system and its proponents argue that it at least gives clinicians and researchers a common vocabulary and insurance companies a basis for coverage of psychiatric illness.
The DSM's opponents have countered that this system is too subjective, not scientifically valid, and subject to abuse. That abuse can come in the form of mislabeling people as mentally ill (homosexuality appeared in the DSM until 1973) or labeling people in such a way that they are more likely to be prescribed medications. If you have observed that more kids seem now to be autistic, or bipolar--some of that increase is simply from increased diagnosis, guided by the inclusion of these entities in the DSM.
DSM 5 (they've changed over from Roman numerals) is about to be released amid enormous controversy. Many critics, including some psychiatric insiders, feel that the DSM 5 is an even less reliable and more potentially harmful tool than its predecessors. In fact, the National Institute of Mental Health (NIMH) has just announced that it will no longer fund research based on the DSM.
This announcement is nothing short of a cataclysm in mental health. Imagine that you have a child who's been diagnosed with bipolar disorder and is on medication that seems to be working somewhat but which also causes weight gain and puts him or her at risk for suicide. You now have the most powerful scientific organization dealing with mental health (NIMH) at odds with the most powerful psychiatric organization (APA) about whether that diagnosis is valid.
Though the NIMH's bold move will likely be positive in the long run, in the short run it will cause great anguish and confusion for patients and their families, as well as complicating and stalling research funding and insurance coverage for mental illness.
While I am not sorry to see the DSM fail, I do not share the view of some, including at the NIMH, that the goal should be to replace it with a system in which mental disorders are ultimately characterized by the neurotransmitters and even the genes that are affected. A hundred years ago, Freud warned of this kind of reductionist view of human behavior and I think his concerns hold true today.
Every day, even as a non-psychiatrist, I see people who suffer from depression, anxiety, obsessions, phobias, addictions, and other psychological torment. Some may benefit from drugs, some from psychotherapy, some from complementary therapies, some from therapies yet to be discovered. It may be that the DSM 5 doesn't contain the best names for their pain, but I hope, amid the current quarrel in psychiatry, that the fact that they're hurting isn't forgotten.
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