Is the DSM-5 still acceptable?

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The new, fifth edition of the Diagnostics and Statistical Manual (DSM) continues to take fire from several fronts as psychiatric experts, political pundits and the international community continue questioning its validity.

The American Psychiatric Association continues to defend the manual, but its relevance is becoming a matter of opinion rather than accepted fact.

The DSM-5 and the ICD

One major blow to the DSM-5, outside of the rhetoric and mud-slinging arguments often made in the popular press, is its irrelevance to medical billing. When the Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996, it required health insurance billing to conform to the world standard of identification for illnesses. For mental health, that standard is not the DSM, but is instead the International Classification of Diseases (ICD) which is produced by the World Health Organization (WHO).

The WHO list does not list criteria for diagnosis, merely a name and general description. This, says the APA, makes it nothing more than a list rather than a manual. The trouble is, world wide, more doctors use it as a diagnostic tool than they do the DSM. Further, it's far more accessible, being made to be portable and low cost – it can be freely downloaded from the WHO's website and printed copies are inexpensive in most parts of the world – often being handed out free of charge to healthcare providers. The DSM, on the other hand, is a thick, expensive manual sold exclusively by the APA and is, by their own admission, a major source of their income.

Criticism of the DSM

Critics of the DSM point out that its panel members – the people who make the decisions as to what should be and should not be included, and how they are to be included (including exact verbiage) – often have extensive ties to the pharmaceutical and insurance industries, both of which have a big stake in the mental healthcare game financially. A New England Journal of Medicine report showed that 68 percent of the DSM-5 task force had reported personal ties to the pharmaceutical industry. Those were just those self-reporting their ties.

Other critics point to the manual's loosening of diagnosis thresholds for many popular illnesses, those with expensive pharmaceutical treatment options, have been changed in the DSM-5. This leads to over-diagnosis and treatment of patients who probably do not require it.

Conflicting Manuals

Proponents of the DSM point out that it is far more detailed in its listing of disorders and more specific in its titles and descriptions. For example, many disorders such as "binge eating disorder" and "disruptive mood dysregulation disorder" in the DSM-5 are merely "other.." in the ICD.

Given that the DSM and the ICD are both aiming to be setting the norms and standards for diagnosis, the conflict is not something to be simply brushed aside. The two simply cannot work together for long without coming into conflict.

An Unreliable Resource

With study after study implicating the DSM and its creators in monetary scandals and collusion with pharmaceutical makers, and with the multiple public scandals and call-outs of the manual's misrepresentation of some diseases and which fundamentally question some of the changes or additions therein, the DSM-5 stands on shaky ground at best.

One of the most telling of those arguments against the DSM is by far the most damaging: much of the manual is based on belief and expectation, anecdotal evidence and experience, but not empirical, tested, scientific data. This, says neuroscientist and neuropsychiatrist Nancy Andreasen, one of the most outspoken critics of the DSM, destroys any credibility it could possibly have with medical science.

This, many argue, is the reason that the mental illness rate in the United States is at 26.4 percent while the worldwide rate is just over 10 percent by comparison. The DSM provides incentive to over-diagnose, it is said, and loosens requirements for many mental illnesses to facilitate that.

Sources: American Psychological Association, New England Journal of Medicine, DSM5.org, Schizophrenia Bulletin and NBC News

 
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