Is It Time to Scrap the Manual on Mental Illness?

After 11 years of working on the new DSM, some are saying that it’s time to retire the manual and think abut mental health entirely differently

Richard Masoner

For nearly 11 years, the psychiatric community has been discussing, revising, debating and crafting the next issue of the DSM—the Diagnostic and Statistical Manual of Mental Disorders. The DSM is psychiatrists’ map for diagnosing mental illness: everything from depression to autism to eating disorders is in there. It’s an incredibly important document, and as such has been at the center of intense debate. In fact, some are saying that it’s time to retire the DSM and think about mental health entirely differently.

The National Institute of Mental Health struck a major blow to the DSM when announced it would no longer use the manual’s categories to direct its research. The April 29th announcement states:

The diagnostic system has to be based on the emerging research data, not on the current symptom-based categories. 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.

That is why NIMH will be re-orienting its research away from DSM categories. Going forward, we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system.

The NIMH will replace the DSM with their own document, the Research Domain Criteria (RDoC). The announcement from the NIHM wouldn’t surprise those who have been following the organization. Science Insider reports:

Although Insel’s blog was reported as a “bombshell,” and “potentially seismic,” NIMH’s decision to scrap the DSM criteria has been public for several years, says Bruce Cuthbert, director of NIMH’s Division of Adult Translational Research and Treatment Development. In 2010, the agency began to steer researchers away from the traditional categories of DSM by posting new guidance for grant proposals in five broad areas. Rather than grouping disorders such as schizophrenia and depression by symptom, the new categories focus on basic neural circuits and cognitive functions, such as those for reward, arousal, and attachment.

Some applauded the move, but others say that while the DSM is certainly flawed, scrapping it altogether isn’t the way to go. Helena Kramer, a researcher responsible for field trials of the DSM-5, told Science Insider that while Insel is right to say that research domains are the way to go, that doesn’t mean it’s right to toss the DSM. ”The DSM is a series of successive approximations,” she said—no one should assume it can get everything right all the time.

Others saw it as further evidence that psychiatry as a whole is skating on thin ice. At Scientific American, John Horgan puts it this way:

So the NIMH is replacing the DSM definitions of mental disorders, which virtually everyone agrees are profoundly flawed, with definitions that even he admits don’t exist yet! What more evidence do we need that modern psychiatry is in a profound state of crisis?

But the idea that the NIHM is leaving behind the DSM isn’t entirely accurate, reports Ferris Jabr, also at Scientific American. The institute’s Cuthbert wrote to Jabr in an email that the “sensationalist headlines out there are entirely misleading…RDoC is intended to inform future versions of the ICD and DSM; we have no intention of coming out with a competing system.” Jabr writes that it’s seductive and easy to bash the DSM, even if it’s not totally accurate:

People get something akin to schadenfruede out of condemning the DSM and all of modern psychiatry along with it. Super important government institution rejects psychiatry’s beloved Bible! Psychiatrists in crisis. Everything will change.

When in reality, he says, things are far more complicated. The debate over diagnosing and treating mental illness isn’t going away any time soon. And while everyone seems to be working towards the same goal—a better way to diagnose and treat patients—no one can quite decide how to get there. How would the DSM diagnose that condition?

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