The fight over the DSM
Anew diagnostic manual prepared by the American Psychiatric Assn. either trivializes serious conditions, needlessly encourages hurtful stereotypes or succumbs to political correctness, depending on whom you believe.
Even experts will question one classification or another in the draft fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, which is why it’s been posted on the Internet for comments years before its expected publication in 2013. But the intention of the authors -- to define more precisely which conditions require psychotherapy and how they’re related to one another -- is laudable. And some of the early objections seem rooted more in politics or perception than in science.
For example, some parents of children with Asperger’s syndrome, which is characterized by social unease and obsessive interest in arcane subjects, apparently resent the fact that, instead of being its own category, Asperger’s will be grouped with three other syndromes under the heading “autism spectrum disorders.” That’s of concern because they don’t want their children labeled autistic.
It’s important to be sensitive, but not to the point of minimizing connections that can aid treatment. Other critics fault the manual for being too politically correct, as reflected in terminology changes such as “gender incongruence” in place of “gender identity disorder” to describe children uncomfortable with their gender. That and other changes -- such as the replacement of “mental retardation” with “intellectual disability” -- do seem designed to avoid stigma, but they do so without changing the meaning, so we don’t see anything wrong with that.
The manual is also being criticized for including a supposedly arbitrary inventory of addictions -- gambling and binge eating are in but not sex or Internet overuse. That debate is a reminder that whether a problem is or is not included in the DSM can have real-world consequences: The manual is used by health insurers to decide what treatments to cover, as well as by state agencies, schools and courts.
The variety of criticisms reflects the fact that, compared with other fields of medicine, psychiatry lacks precision and that psychiatric classifications often have moral and political overtones.
With all its imperfections, the DSM serves an important purpose for psychiatrists and doctors in general practice. That doesn’t mean therapists can’t be alert to specific complaints from their patients that confound or combine the categories. As with the Bible, in some cases the manual should be taken not literally but seriously.