Yes and no. David Kupfer, chair of the DSM 5 Task Force, and others, have defended the soon to be published manual, stating that “the approach of the work groups has been conservative, aimed at defining mental disorders that have a real impact on people’s lives, rather than expanding the scope of psychiatry” (Medscape Medical News). Although we have yet to know the particulars, we are aware, through statements in the public media, that the DSM 5 will combine Axes I (Clinical Syndromes), II (Development Disorders and Personality Disorders), and III (Physical Conditions), provide sections for psychosocial and contextual factors that include replacement of Axis IV, the stress axis, and Axis V, the “disability” axis, and place more emphasis on dimensional than categorical assessment.
CONTROVERSIAL CHANGES AND ISSUES
- The removal of Asperger’s Disorder and its inclusion within the Autism Disorder Spectrum, much to the dismay of individuals and families with Asperger’s Disorder. Less controversial have been the additions of Binge Eating Disorder, Excoriation Disorder, and Hoarding Disorder, alleged to be strongly supported by research outcomes.
- The work groups are to be commended for responding to criticisms that the DSM pathologizes normal human suffering by distinguishing in the DSM 5 between grief, depression, and bereavement. This recognizes that grief reactions are expected and normal, but that prolonged bereavement can precipitate a major depressive episode.
- We believe the DSM 5 has made a step in the right direction by formally acknowledging the impact of trauma on mental health, giving it its own chapter, entitled, “Trauma and Stress Related Disorders,” attending more to behavioral symptoms related to trauma and refining symptom clusters in a way useful to clinicians.
Criticisms on Ties to the Pharmaceutical Industry
What continues to be disturbingly absent, however, is any acknowledgement or recognition in the DSM 5 of the contribution of culture, behavioral or interpersonal strengths, or mental health promoting behaviors. The manual remains focused exclusively on pathology, dominated by the medical profession with only lip service paid to the contributions of psychology, nursing, social work, and other mental health professions. It appears overly dependent upon and influenced by the pharmaceutical industry. Astonishingly, the latter flaw was recently defended by David Kupfer, DSM 5 chairman in the Medscape article previously cited by pointing out that no DSM 5 task force member was allowed to own more than $50,000 in stock in pharmaceutical companies or have more than $10,000 in annual income from pharmaceutical companies! How is this an argument against undue influence? How about NO income from the pharmaceutical industry as a requirement?
Absence of Mind / Body Health Promotion
The DSM 5 continues to ignore precisely those behaviors and well documented “common factors” that best predict outcome in mental health treatment, that is, characteristics and behaviors of the patients themselves, the nature of the clinician-patient relationship, and fortuitous events. Any thoughtful reader will notice these factors every day in popular press accounts or personal experiences of culture changes in nursing homes—such as the teaching of music or the experience of gardening—that more effectively reduce depression, social isolation, and disruptive behavior than does medication. Also absent are narratives on the practice of yoga, drama, and journal writing in prisons; the enhancement of accurate diagnosis and thus effective treatment of both medical and psychiatric conditions through the use of cultural brokers; and cultural specific methods of communication. So why is there no exploration of these documented mind/ body health promoting behaviors in the diagnostic system of the DSM?
Mental Health of the Community, Not Only the Individual
The emphasis on social support, neighborhood cohesion, exercise and other mental health promoting behaviors are becoming legend. They are as vital to the mental as well as economic health of one’s community. The mental health of individuals, as well as the ability to cope with mental disorder, is inextricably intertwined with the mental health of families and communities. The agonizing, unspeakable gun- related tragedies are hopefully engendering a deeper and more relevant discussion of complex causation and ultimately greater clarity about mental health and well-being. While these discussions have gone in the direction of whether gun control or better mental health treatment are the answers, these interwoven contexts require complex, comprehensive responses and attention to prevention as well as meaningful responses for individuals and communities.
Perpetuating Diagnostic Labels Instead of Constructing Solutions
The DSM 5 attends to the negative, pathologically based construction of diagnostic labels that describe perpetrator behavior and symptoms in these violent episodes. However, it does little to promote critical thinking regarding a deeper understanding of the complex contextual factors that have a role in creating these tragedies. That understanding would assist immensely in providing direction for prevention and interventions and policies that would support healthy individuals and communities.
Obviously the DSM cannot address everything or be all things to all people. Nevertheless, there is an alarming and continuing weakness in psychiatric diagnosis that has not been addressed in the proposed manual. Our proposed Axis VI, incorporating resiliency and diversity factors, honoring patient contexts, recognizing culture and the contributions of positive psychology, we feel, would have begun the essential process of addressing the real complexity and strengths inherent in our patients and their communities. It is time that psychiatry acknowledges the rich contributions of the other mental health professions, and of the experiences of the patients themselves as well as their families and communities, by bringing all of us to the table in a meaningful way.