Shrinking Normality- The ever-expanding DSM

Suzie Chick

One the key developments in mental health over the past 50 years or so has been the rapid expansion in diagnoses. It seems every year, more and more conditions are identified. This growth is clearly demonstrated by the evolution of the bible of psychiatry, that being the Diagnostic and Statistical Manual of Mental Disorders or DSM for short.

The DSM is a handbook used by psychiatrists and other mental health professionals to help diagnose mental health conditions. The DSM essentially contains a list of the recognised illnesses accompanied with a list of criteria, which need to be met in order for diagnosis to be successful. The DSM was first published in 1952 and listed 106 recognised conditions. Since then there has been five official amendments, with the latest version being published in May 2013. The DSM has grown with each amendment, and almost trebled in the number of diagnosed conditions by its forth edition in 1994 (with a total of 297).

How many more conditions could there be?

This rapid expansion greatly concerned the professional community. Would the DSM continue to grow at this rate into perpetuity? How many more conditions could there be? How can people working in mental health keep up with these changes? In response to the outcry, the task force behind the DSM V announced there would no increase from the 297 conditions listed in DSM IV. Instead, and rather sneakily might I say, any new conditions were coupled with pre-existing ones, acting as sub categories with each other? So in effect DSM V did increase in size from the last version but not explicitly.

Are we coming up with more and more possible conditions because we are unwilling to truly embrace the uniqueness of individuals?

Reflecting upon this, I begin to wonder if the rise in diagnosable conditions suggests more than just our enhanced knowledge and understanding of the human mind? Could it also help alleviate our anxiety of what it is to be human? After all if we can pinpoint, describe and best of all label someone, then their behavior becomes rationalized. Are we coming up with more and more possible conditions because we are unwilling to truly embrace the uniqueness of individuals? Have we become obsessed with placing people in boxes? Is the growth with every DSM less about our knowledge and more about our need for certainty and our reluctance to sit with the unknown?

I will certainly own up to feeling somewhat relieved when I am sitting with a client, particularly during a therapeutic assessment (so meeting them for the first time), and they name a diagnosis, say bipolar or borderline personality disorder. I can hear my inner voice saying “ah got it, that makes sense” when previously I had been sitting with confusion and an increasing level of anxiety and panic. I can feel comforted that another professional has seen or experienced what I have with the same client. And so too can a diagnosis help the individual, they can get access to appropriate treatment, become empowered through gathering knowledge and connect with others in a similar position.

I can feel comforted that another professional has seen or experienced what I have with the same client.

However I know also that over-reliance on a diagnosis can be a dangerous strategy. Sometimes it can allow people to be defined by their diagnosis and to use it, as an excuse for all that is “wrong” with their lives. Essentially responsibility for themselves gets avoided and displaced. They can become resigned to their plight and use their diagnosis as an absolute barrier to growth. A diagnosis is not all that any person is; we are all so, so much more.

Despite the mixed blessing of diagnosis, however, we seem to have a voracious appetite to identify more and more mental health conditions, as exemplified by the growth in the DSM. Have we gone too far I wonder? If we continue to expand the list of recognised conditions, does diagnosis start to become meaningless?

The expansion of the DSM since its origin in 1952 has not gone unnoticed amongst the large pharmaceutical companies and they have responded in kind.

And could there be darker, unethical forces at work here? With more conditions, there can be an increased scope for treatment, including medication. The expansion of the DSM since its origin in 1952 has not gone unnoticed amongst the large pharmaceutical companies and they have responded in kind. Or dare I suggest, that maybe the power play is the other way round. How free from conflicts are the authors of the DSM (being the American Psychiatric Association) from being influenced by the financial incentives on offer by these large Pharmaceutical companies? Who is really calling the shots here?

The British Psychological Society described the ever-expanding DSM as shrinking the pool of people who may be considered normal in society “to the size of a puddle”

The British Psychological Society described the ever-expanding DSM as shrinking the pool of people who may be considered normal in society “to the size of a puddle”. It seems the growth in mental health diagnoses may have shrunk normality. Just dealing with the every day trials and tribulations of life, the struggle of what it is to be human, seems to be under threat from those in mental health wishing to label and categorize. A perfect example of this is how the exclusion of bereavement from diagnosed depression was removed in DSM 5. This move, essentially naming grief as a mental illness, has understandably proved controversial.

Normality might not only have been shrunk but also pathologised. In a sense mental illness could become the new norm. This was one of the main arguments put forward by James Davies in his book Cracked- Why Psychiatry is doing more harm than good. Davies describes the DSM as a “great work of fiction” and explains that in his opinion more and more people are being wrongly medicalised. Davies suggests that we have reclassified the normal as abnormal and at the heart of this delusion lies the DSM. Davies’ work raises some important questions regarding how we as a society wish to view and define mental health, and at present how this major area is being left in the hands of the authors of the DSM.

It seems to me that we are at a crossroads when it comes to mental health conditions. If we continue down the widening DSM road, we may all soon carry a diagnosis or two. However, now the debate is conscious, we have a choice to take a different route. To reexamine how we view mental health more generally and how we can create a diagnostic approach, which serves the best interest of the patient and society at large. So my advice, for what it’s worth, to the authors of the next DSM is to put down your pens and embrace the age-old adage ‘less is more’.

 

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