The DSM

The process has begun to update the DSM (the Diagnostic and Statistical Manual of Mental Disorders). The DSM, currently in version IV (Aka, "The DSM-IV"), defines what constitutes mental illness for treatment and insurance purposes. The question, however, of what gets included or excluded is controversial because what is considered a mental illness has been changing so quickly in our culture.

You see, unlike in fields like Cardiology or Oncology, the fundamental disease processes of mental illness are still known. Thus, grouping illnesses by common origin (etiologically) is impossible. The approach was abandoned as the grand psycho-theories of people like Freud collapsed. Instead, the editors of the DSM take a taxonomic approach, grouping symptoms together into common clusters. A certain cluster of problems has been identified as "Major Depression" and another "Schizoaffective Disorder."

This becomes a huge problem in something called "differential diagnosis." How do you know, for instance, whether someone has a "Panic Disorder" (Code 300.01) or "Obsessive-Compulsive Disorder" (300.3) or even "Post Traumatic Stress Disorder" (309.81). The symptoms can be virtually identical, and it ultimately becomes a clinician's judgment call about where the person fits best.

Even more interesting, to me, is the multiple categories where one of the criteria is something like "...behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning." In other words, if the patient thinks is a big problem, it's a big problem, otherwise, it's not. This criteria is especially common in the sections on sexual dysfunction and seem, to me, to be a cop-out. Essentially anything you might do or desire is considered okay until it impairs "function" or causes "distress." Am I the only one that thinks that's a strange way to define illness?

So they are revising the big book of badness. No doubt the number of diagnosable illness will continue to increase (as it has with every version of the book). The big winner will be the drug companies.

One of the therapist friends told me that she found the DSM-IV to be utterly useless. She she didn't get reimbursed by insurance she never even opened it anymore. There is wisdom there!

-t