DSM IV

Nearly 20 years in the making, the American Psychiatric Association is preparing an update to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, or DSM V.

This is no small matter given that the DSM is used to diagnose and treat mental illness, leading to all sorts of outcomes, good and bad.

In an article in The Wall Street Journal titled Prescriptions for Psychiatric Trouble, Dr. Sally Patel, a psychiatrist at Yale, presents the pros and cons.

"The problem is that the changes don't really advance psychiatry. Worse, some are prescriptions for trouble. One of the most controversial is the creation of a diagnosis called 'psychosis risk syndrome.' Granted, the motivation is laudable: to identify adolescents or young adults at risk for developing serious mental illnesses marked by hallucinations and delusions. What doctor wouldn't want to intervene early to ward off an affliction like schizophrenia? But a diagnosis believed to foreshadow a full-blown psychotic illness has the potential to be highly stigmatizing. That is especially unfortunate if the labeled individual does not even go on to develop such an illness—and the chances of that are estimated at about 70%, according to a 2009 Journal of Clinical Psychiatry review paper, 'Intervention in Individuals at Ultra-High Risk For Psychosis.'

"To complicate matters further, treatment is not especially effective in forestalling psychotic illness in the minority destined to develop it. And since we don't know who those people will be, otherwise healthy kids will be exposed to potent antipsychotic medications and their side effects, such as diabetes and weight gain."

More diagnoses means more pharmaceutical treatment.

"How do we know, for example, that a person diagnosed with major depressive disorder (the formal designation for pathological depression) is not actually suffering from a bout of natural if intense sadness brought on by a shattering loss, a grave disappointment or a scathing betrayal?"

In college I read the work of Dr. Thomas Szasz, including The Myth of Mental Illness.  Since its publication in 1960, Szasz has been dismissed as a crank by many in the APA, which makes his positions all the more important when a psychiatrist who led the revisions to DSM IV today warns of yet more diagnostic overreaching.

"The DSM V would dramatically raise the rates of mental disorder in the general population," said Allen Frances, head of the team that revised the fourth edition of the manual. "Some of the new diagnoses would be extremely common and pharmaceutical marketing would amplify the risk of their being found. This means, of course, that a lot of otherwise normal people will be medicated."