A therapist talks to her patient.
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The attempt to catalog all the ways that Americans can go crazy dates at least to 1840, when the Census included a question on "idiocy/insanity." From those two simple categories, we now have more than 300 separate disorders; they are listed in a 943-page book called the Diagnostic and Statistical Manual of Mental Disorders, or DSM for short. The book is important because doctors, insurers and researchers all over the world use it as a reference, a dictionary of everything humanity considers to be mentally unbalanced.
This week we got the first comprehensive look at what might go into the book's latest version, the DSM-5. Currently, the DSM is disjointed and disorganized -- at times well researched and at times anachronistic. The present version, the DSM-IV-TR (the TR stands for "text revision"), was published in 2000. It begins with "mild mental retardation" moves on to common illnesses like depression and odd ones like dyspareunia (painful sexual intercourse not due to a medical condition) and ends with the vague "personality disorder not otherwise specified." The rhyme and reason behind the DSM have always been murky; the book, like our brains, is a huge, complicated beast.
The American Psychiatric Association (APA), which publishes the DSM, has long wanted the fifth version to be a more rational, understandable document, but that's not proving to be easy. Publication has been delayed at least twice, and the association now doesn't expect to produce DSM-5 until 2013, 14 years after research on it began. One reason is that there are so many stakeholders: patients, shrinks, HMOs, academics. Patients want their illnesses covered; shrinks need to get paid academics want definitions to be consistent with research -- research that is itself uneven. Sometimes, DSM changes can be made on the basis of long-term, peer-reviewed studies. But other times, such gold-standard research data is lacking, and changes must be made on the basis of consensus among clinicians. The process is fraught and confusing, even for those in the middle of it.
Still, the launch of dsm5.org -- where suggested changes to the DSM were posted Feb. 10 for public comment -- is a major step. Here are five ways the APA is proposing to address major criticisms of older versions of the book:
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