What the DSM-5 means for students

The fifth edition of the Diagnostic and Statistic Manual of the American Psychiatric Association (DSM-5) was published earlier this year amid much comment, some positive, some negative.  A great deal of this commentary is relevant to students.

The DSM is a set of labels for various mental disorders including symptoms and thresholds for severity that help clinicians diagnose mental illness. Diagnosis is an important first step in treatment, and is also a requirement in many cases for public health assistance.

The positive commentary around the DSM-5 revolves around two key points. First, as noted by Dr Darryl Watson, clinicians need labels – families and sufferers want a diagnosis, as do research funding bodies and insurance companies, and psychiatry needs shorthand terms around which to build its technical discourse. The DSM-5 updates psychiatry’s labels to reflect the last two decades of research.

Second, the DSM-5 recognises a broader spectrum of illnesses, allowing previously undiagnosed conditions to be precisely identified and taken more seriously. Sufferers will now be eligible for insurance and health care assistance.

Clinicians are in agreement over the first point, but the second has attracted heavy criticism, much of it arguing that the DSM-5 represents ‘diagnostic inflation’ and allows normal people to be diagnosed as mentally ill.

Arguably the loudest voice of criticism has been Dr Allen Francis, lead editor of the DSM-4. In his book, ‘Saving Normal’, He acknowledges the good intentions of the DSM-5 working groups but warns that the diagnostic creep of DSM-5 will lead to the over-medication of the ‘worried-well’.

The first reason for this is that the DSM-5 will make it easier for primary care physicians to believe they have correctly identified a mental illness and issue a script for it. Francis notes that before DSM-5 in the United States ‘80 per cent of prescriptions’ for psychotropic drugs were ‘written by primary care physicians with little training in their proper use...after rushed seven minute appointments’.

The DSM-5 does not help this situation because throughout its crafting ‘decisions were mostly made by and for psychiatrists – ignoring the fact that...they write only a small minority of prescriptions for all psychotropic drugs’.

While psychiatrists can now take their professional discourse further, there is greater potential for misunderstandings among the lay audience and misdiagnoses by non-specialists. For example, DSM-5 introduces the concept of ‘behavioural addictions’, which has the potential to see anything that we like to do a lot labelled as deviant. 

The second reason is that the DSM-5 focuses excessively on symptoms and overlooks the narrative arc of a patient’s life and its contribution to a patient’s illness. As Francis notes: ‘DSM definitions do not include personal and contextual factors, such as whether the depressive symptoms are an understandable response to a loss, a terrible life situation, psychological conflict or personality factors’.

This point has attracted criticism on a different front from researchers. Dr Thomas Insel, director of the American National Institute of Mental Health, for example, argued prior to the release of the DSM-5 that it was overly focussed on symptoms and placed insufficient emphasis on the bio-chemical and genetic causes of mental illness.

Francis emphasises that these are important perspectives for researchers to keep in mind. But his worry is to do with the misuse of the DSM by practitioners and laypeople not at the coalface of research, and the consequent medication of people who are not suffering from severe illness but from everyday problems.

Francis is particularly worried about the over-diagnosis of major depressive disorder (MDD) among those who are just feeling sad: ‘The DSMs have made it too easy to get a diagnosis of MDD. The biggest weakness is not recognising the role of severe life stress in causing reactive sadness’.

A big part of the problem, argues Francis, is the pharmaceutical industry, which has a strong financial incentive to increase prescriptions: ‘only a very few people have severe mental illness, many more have mild mental illness, but the real mother-load of market share is the worried well’.

Francis argues that the pharmaceutical industry has perpetuated a narrow biological view of mental illness because it increases sales: ‘[Pharma] has achieved fantastic revenues by promoting the idea that many of life’s expectable problems are mental disorders due to a ‘chemical imbalance’ that can be solved with pill popping’.

These are very important points for students, who regularly experience feelings of stress, sadness, depression and anxiety for very normal reasons: exams, break-ups, challenges to their identity, and profound changes in life circumstances, for example.

These feelings can persist and develop into mental illnesses, but medication may not be the best treatment: ‘Doctors bought the line that all depression results from a chemical imbalance in the brain and therefore requires a chemical fix—the prescription of an antidepressant medication. This is absolutely true for severe depressions, absolutely false for most milder ones. The proof of this pudding is that psychotherapy is just as effective as medication for milder depressions, and neither has a big edge over placebo.’

More worryingly, unnecessary medication might actually impede healing. As Francis notes: ‘Prematurely resorting to medication short circuits the traditional pathways of restorative natural healing – seeking support...making needed life changes, off-loading excessive stress; pursuing hobbies and interests, exercise, rest, distraction, a change of pace. Overcoming problems on your own normalises the situation, teaches new skills, and brings you closer to the people who were helpful. Taking a pill labels you as different and sick, even if you aren’t’.

It is important to note that Francis is not opposed to medication per se, or to psychiatry, which he is a staunch supporter of. His priority is: ‘first to alert people who don’t need treatment to avoid it, but equally to encourage those who do need treatment to seek it out and stick with it’. For more acute disorders, pharmacotherapy is the most effective treatment, but for milder disorders, evidence demonstrates that cognitive behavioural therapy and exercise are just as efficacious as medication.

For students, perhaps Francis’ best advice is: ‘the decision whether or not to take a psychiatric pill or enter into psychotherapy is often life changing. Never do it casually or passively’.