By Joel Paris, MD
The reception of DSM-5 has been marked by very divergent points of view. The editors of the manual congratulated themselves for their achievement in an article for the Journal of the American Medical Association entitled “The Future Arrived.” Yet critics remained adamant, and their views have had wide currency in the media. Those most hostile to psychiatry accuse DSM-5 of being an unscientific collection of dubious categories. Others focus on the way that DSM-5 undermines the concept of normality.
Perhaps the most stinging critique came from Thomas Insel, Director of the National Institute of Mental Health, who has stated that psychiatry “deserves better.” Insel wants to abolish all categories of mental illness, and replace them with a complex scoring system to describe the dimensions of psychopathology. His long-term agenda is to base psychiatry on neuroscience. But these ideas, however ambitious, cannot be supported at this point by empirical data.
The voices of moderate critics (a group I hope I belong to) have not been fully heard. If you sit down and read DSM-5, it is not dramatically different from DSM-IV. Yes, a few categories (generalized anxiety disorder, adult attention-deficit hyperactivity disorder) have been expanded. Yes, grief is no longer an exclusion for depression (although the manual cautions practitioners about making the diagnosis in the bereaved). But the most radical ideas proposed for DSM-5 have been dropped, or put in an Appendix (Section III), mostly for lack of evidence. Thus, risk psychosis has been removed, and the classification of personality disorders is unchanged.
Why then has opposition to DSM-5 been so passionate? Of course, some people will take any opportunity to bash psychiatry. But the main problem is that the process of revision was botched. Ambitious ideas were floated, most of which lacked empirical grounding. Moreover, the wish of the editors to create a “paradigm shift” led them to exclude important experts from the revision process—particularly those who were prominently involved in writing DSM-IV. If you are writing a document that cannot yet be based on solid science, you should at least work harder to obtain consensus.
My view is that while DSM-5 is flawed, it only reflects what is happening to psychiatry as a whole. You can’t blame the manual for the rampant over-diagnosis and over-treatment that afflicts contemporary practice. Also, as research shows, most clinicians haven’t followed previous editions of the manual carefully, and they won’t use DSM-5 systematically either.
What critics and supporters can lose sight of is that DSM-5 is only a provisional system for the diagnosis of mental illness. We just don’t know enough to do better. And we should not believe those who claim that breakthroughs in research are imminent. Understanding the brain, an organ that contains 100 billion neurons, will take decades, possibly a century. Moreover, even a perfect model of the brain could never be the basis of a complete theory of mental illness. You need to apply higher levels of analysis, ranging from an understanding of the psychosocial environment to the concept of mind.
For these reasons, I find much of the commentary on DSM-5 to be misplaced. Instead of supporting or attacking a book, we need to keep in mind how little we know about mental illness. While many psychiatric interventions are effective, that is as much a result of luck as of science. Let’s be humble, and remember that DSM-5 is just a tool, and it is not the only one clinicians can use. Most of the problems with psychiatric diagnosis will not be answered in DSM-6 — and probably not in any of our lifetimes.
Joel Paris is a professor of psychiatry at McGill University (Montreal, Canada), and a research associate at the SMBD-Jewish General Hospital, Montreal. He is the author of 15 books, most recently The Intelligent Clinician’s Guide to the DSM-5®, and 183 peer-reviewed scientific articles. read his previous blog post “Clinician’s guide to DSM-5.”