Is psychiatry’s bible still in the dark ages?

New Scientist recently published an article1 describing the conflict that has emerged in American psychiatry over the upcoming revised version of the DSM (Diagnostic and Statistical Manual of Mental Disorders), frequently referred to as psychiatry’s bible.

From my point of view, disagreement over the diagnostic approach employed by the DSM is decades overdue. I initially encountered the DSM2 in the ’80s when I was working on my master’s degree. My master’s thesis examined how (and how much) the media influence an individual’s perceptions and eventual behavior, so I took a mix of graduate-level classes in communications, psychiatry, sociology and several other areas. Even at that time, the DSM already was used almost universally as the resource for diagnosing psychiatric disorders.

What struck (and bothered) me from my first encounter with the DSM was the process through which it diagnosed disorders — it diagnosed an individual’s illness solely on the basis of the symptoms observed. In other words, the root cause of any psychiatric ailment was irrelevant when making a diagnosis. And since diagnosis drives treatment, that meant that treatments were being prescribed on the basis of symptoms, not underlying causes.

When I questioned my instructors about the standardized approach embodied in the DSM, my concerns were dismissed and I was informed that, “the science does not yet exist to detect underlying causes for mental illness,” or even worse, “many/most disorders of the mind do not have a physical cause.” Clearly, I was just a naïve graduate student.3

Now twenty years later, the DSM is undergoing revision for its next edition (DSM‑V, currently scheduled for release in 2013) and senior voices in the psychiatric profession are (finally!) publicly raising concerns over diagnosing mental illness on the basis of symptoms, not causes. This is an opportunity for the American Psychiatric Association (which publishes the DSM) to revamp the manual and bring it in line with the science and medicine of the 21st century. New Scientist has proposed an approach that would turn the DSM into a “living document” so that it continues to evolve as we learn more about the human mind and the underlying causes of psychiatric disorders.4

Whether the American Psychiatric Association  employ’s New Scientist’s recommendation or some other revamp of the DSM, it’s time to move beyond the uninformed days of psychiatry diagnosis based on symptoms alone.

1. Psychiatry’s civil war, New Scientist, 12 Dec. 2009 [↩]
2. In those days, it was DSM-IIIR, meaning the revised third edition of the manual. [↩]
3. At that time, I was reading numerous science fiction stories that extrapolated the physical basis for various psychiatric disorders. A typical example was “The Ethics of Madness” by Larry Niven, which dared to imagine a future where paranoid schizophrenia could be treated/cured by simply adjusting the individual’s biochemistry. [↩]
4. Psychiatry’s bible: Its time has passed, New Scientist, 12 Dec. 2009 [↩]