Experts weigh pros and cons of revamping mental health manual

Scientists are debating what constitutes normal and pathological behavior with the release of the draft of the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders.

The manual officially dictates what symptoms define a mental disorder and is used widely by psychologists and psychiatrists.

The draft, over a decade in the making, will indirectly determine what disorders insurance companies cover and what types of research funding agencies will sponsor. After additional periods of review, the final version will be released in May 2013.

Because mental health research is highly interdisciplinary, the revision process for the DSM has taken many years, said Theresa Walls, professor of History and Sociology of Science. “You have to plow through a lot of ‘small-p’ politics.”

Each version contains more content and reflects more sophisticated research, Walls said, adding that if each version were put side by side, the books’ spines would grow progressively thicker.

The first manual, published in 1952 in response to World War II and trauma observed in returning soldiers, contained 60 disorders. The new draft lists more than 400 conditions.

The objective of the manual is to add “consistency” to the language mental health professionals frequently use, Walls said.

Often, changes to the manual reflect changes in social context, according to Walls. “Things that deviated from the social norm were considered abnormality or disease states,” she said.

Homosexuality, for example, was once included in the manual, but was taken out in 1973.

Psychiatry has historically been “behind” in medicine, she added. Psychoanalysis, which may be perceived as a “dinosaur” in the field, still plays an important role despite a growing emphasis on biology, Walls said.

One hot topic discussed by researchers is the introduction of a categorization for individuals thought to be at a high risk for a disorder but who are not fully symptomatic, according to Monica Calkins, a Penn Psychology professor.

While risk assessment enables a more preventative approach to treatment, some argue this at-risk diagnosis may subject a patient to social stigma and could harm future insurability.

The draft also proposes a dimensional approach to diagnosis, shifting from a binary system to one that considers the severity of multiple symptoms.

Some scholars, however, are critical of the DSM draft.

“Coming up with an objective, reliable system for determining what’s an illness and what’s normal and what’s abnormal in mental health is really impossible,” said David Barnes, professor of History and Sociology of Science.

He said behaviors once considered normal just 10 years ago have been pathologized, causing “philosophical problems” to “wrestle with.”

The finalized manual will necessitate an adjustment period for clinicians, researchers, insurers and educators.

Calkins, who was completing her degree during the transition from one DSM to another, said her own research in schizophrenia was carried out using both systems.

She expects the authority of the current DSM-IV-TR won’t instantly disappear, as recent research has yet to be published.

Graduate students might be more sensitive to the draft because it affects what research will be eligible for funding, said Emily Gentes, a third-year doctoral student in clinical psychology. She added that before a new DSM is published, “there’s a rush to publish things while they’re still relevant.”

Insurance companies will also have to revise their coverage plans and play “catch-up” for several years once the manual is finalized, said Jonathan Moreno, professor of History and Sociology of Science. “The system is going to have to respond.”

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