Another Wrench in the Mental Health System: DSM-5 Rejected by NIMH


May 7, 2013; Time Magazine, “Health & Family”

The American Psychiatric Association periodically updates its “bible,” the Diagnostic and Statistical Manual of Mental Disorders (DSM). But now, just as the fifth edition is to be released, the National Institute of Mental Health has essentially rejected its categorical sorting. Dr. Thomas Insel, NIMH’s director, said in a blog post last week that “NIMH will be re-orienting its research away from DSM categories.”

The DSM is used not only by practitioners to diagnose conditions, but also by insurance companies to determine treatments to be covered, so it is a socially powerful document. Insel, however, believes that the DSM is less than scientific.

Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain… Imagine deciding that EKGs were not useful because many patients with chest pain did not have EKG changes. That is what we have been doing for decades when we reject a biomarker because it does not detect a DSM category. We need to begin collecting the genetic, imaging, physiologic, and cognitive data to see how all the data—not just the symptoms—cluster and how these clusters relate to treatment response…Patients with mental disorders deserve better.

One point of discomfort about the new edition of the DSM has to do with the large increase of perceived conflicts of interest among those working on its committees. Critics of the DSM-5 point out that 70% of people serving on its committees for the definition of specific diagnoses have financial ties to pharmaceutical companies. In the previous edition, the proportion was 57%. The process of putting these manuals together is unusual(please consult Jon Ronson’s The Psychopath Test for one description) and reportedly the development of this fifth edition was wracked with conflict.

Dr Allen Frances, who chaired the revision of the previous edition, has spoken out as one of these critics. “People with mild problems are overmedicated and people with severe problems are terribly under-medicated because access to care is terribly underfunded.” Dr. Frances worries that the new edition exhibits a loosening of criteria in several major disorders and could lead to further overmedication. He is quoted as saying “the work on DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology” and has expressed concern about an “inexplicably closed and secretive process.”.

Here is a specific issue, as related in another TIME article:

“One of the new diagnoses that the editors chose to exclude is ‘attenuated psychosis syndrome,’ a condition designated to describe youth who are at high risk of developing schizophrenia—before they develop the full-fledged disorder.

The problem is that only 8% of those categorized as “high risk” because they have close relatives with the disorder or have suggestive symptoms actually go on to develop schizophrenia, according to a recent study. Many critics of the new diagnosis feared that it would legitimize the potentially dangerous practice of administering powerful antipsychotic drugs to youths. With every major manufacturer of antipsychotics already paying out hundreds of millions or billions of dollars in fines for mismarketing these medications to youth and the elderly, the problem of overprescribing is already rampant—particularly in vulnerable populations like foster care children.”

A short description of other criticism can be found at wikipedia under criticism but The NIMH is readying its own diagnostic system, to be called Research Domain Criteria (RDoC), but it is not yet ready. As we said, NPQ would love to hear from those in the field about this issue.—Ruth McCambridge

  • Dr Billy Kidd

    The title of this article about the DSM-5 is quite misleading. The real issue is that the director of the National Institute of Mental Health called for more biological-based research on mental disorders. That is not a rejection of DSM-5. In fact, DSM-5 is the only internationally accepted diagnostic manual used to treat mental disorders, aside from ICD-10 which uses DSM diagnoses for the most part.

    Almost everyone in the psychological community wants more research on the biological origins of mental disorders, including the authors of DSM-5. However, right now there is not enough information to make diagnoses based on the presenting biological problem. It is going to take another 20 years before that can start.

  • HenryHall

    Dr, Kidd writes: The title of this article about the DSM-5 is quite misleading. … . That is not a rejection of DSM-5.

    Dr. Insel, director of the National Institute of Mental Health wrote that “The weakness [of DSM-5] is its lack of validity. ”

    It’s really a stretch to say that saying a medical publication “lacks validity” is anything less than a rejection of it.

    And rightly so, because it really does lack validity which was expressly revealed by the field trials.

  • Graham Dunne

    Dr Billy,

    You are still labouring under the prevailing assumptions that there is a definite biological root cause to be found

    Maybe there is… Maybe there isn’t

    You are also labouring under the misapprehension that the DSM is based on good science – it is not, it has always been a collection of cooked up classifications and sciencey sounding labels, which has steadily become more ludicrous as time has progressed

    This quote is very telling: “However, right now there is not enough information to make diagnoses based on the presenting biological problem.”

    I’m afraid we don’t even know that ,much. If you were taught that, you were mis-taught.

    There’s a lot of ‘Psychiatry under Fire’ typed stuff flying around at the moment and I definitely agree that these titles are not helping. Psychiatry is not under fire at all – it is maturing and developing – as all practitioners ought to be

  • D. S. Arrowsmith

    Let’s start the critical analysis of this document with its title: Diagnostic and Statistical Manual of Mental Disorders. The last time the book offered any advice on statistics was in its second edition of 1968. The editors (in their prefatory material) declared the term “mental disorders” inappropriate in the 1994 fourth edition. So the title of this document should be “Diagnostic Manual.” If the APA can’t arrive at the appropriate designation for this book, they should approach with more humility the sorting and naming of the disorders they aspire to treat.

  • Sandra Rasmussen, PhD, RN, LMHC, CAS-F

    Thanks for this timely update. Any chance we addiction/mental health professionals (teaching, clinical practice, and research) might embrace the ICD criteria in our work? Much billing presently uses ICD codes. The DSM has been “more American” and less “global” in its adoption.

    Sandra Rasmussen

  • Ben Lee

    Well, if it’s not determined yet whether there is a biochemical causality to the ‘disorders’ ‘defined’ in the DSM, HOW is prescribing psychotropic drugs for just about everything in it considered a fitting treatment? If psychotropic drugs (which are baiscally chemicals that alter brain function, right?) make the symptoms go away, that’s a pretty clear finger pointing to biochemical processes causing the symptoms in the first place, right? You’re basically saying here that there is even a possibility that the brain of someone with depression has the exact same biochemical balance as the brain of someone who fits the ‘norm’. Which would make literally no sense, because every symptom in the DSM is based on observing behaviours. Behaviours in general are expressions of brain processes. So saying that two people who behave completely differently have the same balances makes no sense.

    THERE IS ALWAYS a biological root cause to expressed behaviors, even if they haven’t found it yet. And it should be pretty obvious to the general public by now. If something alters the way neurotransmitters do their thing, they’re going to do different things. THEN, you can discuss whether the body, by being genetically predisposed to doing so, causes these deviating brain behaviours itself or whether there is an external factor involved that plays into this genetic predisposition, like metal poisoning, lack of certain vitamins, messed up dopamine levels, whatever…

    My problem is that the DSM, which is basically a marketing pamphlet for the psychotropic drug industry by now, clearly takes vaguely described symptoms, throws them together for reasons unkown and stamps a disorder name on it. I challenge you to find a single person that you couldn’t possibly categorize under any ‘disorder’ mentioned in the DSM right now. It really is that vague. Even to a layman like me, it is terribly distressing that a publication, funded mostly with big pharma money happens to label every human being alive as having a ‘disorder’ that needs to be be treated with products they make billions off… Like I said, the DSM is more of a marketing pamphlet for psychotropic drugs than it is actual science…