Dr Robert London

My hope for the DSM-V

Clinical Psychiatry News - Volume 37, Issue 2, Page 13 (February 2009)

You will be pleased to know that no matter how long you have been neurotic, you will no longer be neurotic by 1980.”

That's how I opened one of my syndicated daily radio programs one year before the DSM-III was introduced back in the late 1970s, when I was a health care broadcaster. The DSM-III was a giant departure and important step forward from the DSM-II.

As some of you might remember, the DSM-II was modeled loosely after some analytic concepts. It was not particularly descriptive. In the subsequent document, 12 neurotic disorders were eliminated, even though the word “neurosis” was important clinically in helping to describe a spectrum of anxiety in which the person in distress wanted relief. The word neurosis got replaced by a series of “disorders” where anxiety was the dominant feature.

In addition, the DSM-III made a listing of symptoms as the lynchpin of diagnosis and that approach continued to be used in the DSM-IV's various revisions, the last of which appeared in 2000.

As our colleagues work on the DSM-V, I would like to offer a few thoughts about how the manual can best serve our profession and our patients. Mainly needed are flexibility, simplicity, and humility.

Recently, I attended a continuing medical education seminar on acute and maintenance care of bipolar disorder. There were five lecturers from major medical centers across the country, all offering scientific and clinical information on this complicated disorder.

Each member of the panel approached bipolar disorder from different perspectives, offering direction to where their clinical and research studies were headed. I say “were headed” because neurobiology and neuroimaging show cerebral changes in the different aspects of bipolar disorder. However, nothing pointed to a cause.

Likewise, it seems there are a great many unanswered questions about psychiatric disorders that are dominating the current research. I am confident that sooner than later, we will know the major causes of major mental illness and will head right to treating causation.

In America today, we have about 46,000 psychiatrists and about 85,000 clinical psychologists. Add to this the larger and larger number of nonmedical therapists doing psychotherapy, including well-trained psychiatric social workers, plus thousands of other master's and nonmaster's level therapists. Then include the many providers using complementary and alternative medicine in treating psychiatric disorders.

Many of these clinicians treat some of the most complicated psychiatric patients with a variety of psychotherapies. In far too many cases, psychiatrists only see these patients for medication management and fail to communicate with the therapists working with the patient.

The point is that the landscape in treating mental disorders has changed dramatically over the last 30 years. So the thinking used to shape the DSM-V should change as well so that it—to repeat—focuses more on flexibility, simplicity, and humility. Such an approach might make the DSM more challenging to create, but the resulting credibility would be worth it. As the old adage goes, “Sorry for the long letter, I didn't have time to write a short one.”

Also, today, the need for transparency is a common theme in politics, and we must make it a theme in psychiatry, too. In other words, we must make sure that the DSM-V is shaped in the light of day. Evidently, total openness has sometimes been lacking. For example, a New York Times article that ran last year on Dec. 18 quotes the American Psychiatric Association as saying that the contributors have signed a nondisclosure agreement to avoid distraction and to prevent authors from making deals to write casebooks or to engage in other projects based on the deliberations without working through the association.

It seems to me that full disclosure of what the DSM people are planning as well as relationships with pharmaceutical companies or any other vested interests should be required of anyone working on the DSM.

The DSM is a solid guide to clearer thinking in the world of mental disorders. A big problem as I see it is that it may be thought of as a bible of mental disorders—which it is not. Rather, it is a highly organized and structured guide. When it reflects our knowledge at its highest levels, the DSM should be a source of pride.

Those who revise and rewrite the DSM need to approach its definitions—again—with flexibility, simplicity, and humility. This is important for the book's credibility and for the many thousands of clinicians who will use it.

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