Using science, not semantics

I’ve always been a bit uncomfortable with the DSM (Diagnostic and Statistics Manual) that is used almost universally for mental health issues and pretty much everything having to do with drug dependence and addiction.

When the controversy over the new DSM-5 was brewing and people were saying that this could significantly affect the number of people with specific mental health issues, that sent up red flags: How could a person’s mental health condition change based on rewriting a manual (unless you were actually stuck on the committee re-writing it, of course)? It started to sound to a layman like me that the entire field of mental health diagnosis (and thus all discussions about potential psychiatric harms of drug use and abuse) were based mostly on semantics.

Thus I was particularly interested in this article by Dr. Harold Kopleicz: The National Institute of Mental Health Declares Independence from the DSM-5

The strength of each of the editions of DSM has been “reliability” — each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.

It is no secret that the DSM is a clinical tool more than a scientific one, designed to compensate for the often unknown “etiology” or cause of psychiatric illness. This has been true since we began perceiving mental illnesses as real diseases of the brain. Lacking objective diagnostic tests — for now — the manual creates a set of clinical categories so that doctors are on the same page, and so that research into treatments could be effectively compared.

Dr. Insel’s “abandonment” of the DSM is in fact a symptom of his optimism that we are now or will soon be able to discover the “real,” biological causes of mental illness. The DSM is inconsistent with this science. “We cannot succeed if we use DSM categories,” he writes. “The diagnostic system has to be based on the emerging research data, not on the current symptom-based categories.”

This really helps me put the DSM into perspective. It also points out the fact that we should be wary of statistics showing numbers of people dependent on, or addicted to, various drugs, as these are also based on arbitrary DSM categories, not actual biological science.

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