Why DO The Texts Keep Getting Bigger?: DSM’s Tendency to Pathologize the Normal

Each subsequent publication of the DSM has gotten progressively larger. We can only imagine what sort of tote bag we’ll need for the upcoming DSM-5.

Now, this doesn’t bother me for its own sake, really. I don’t go on family vacations with the latest volume of the DSM along for light reading.

What concerns me is that the texts grow in conjunction with increased pathologizing of what used to be ‘normal’ (take that as you will) behaviors.

Curious how the DSM-5 will come to win at the weighing-in ceremony?

Of course the committee got itself an addition by incorporating bereavement into depression; has several new and improved mental illnesses in the pipework, assumedly adding to the pagination count; would seem to have been able to offset these page gains by cutting out one-half of the personality disorders–but needs to account for them elsewhere somehow, so there may be no net gain at all weight-wise; is still fiddling around with how to best plan for diagnosis of illnesses on the autistic spectrum, and the explanation alone for who on the spectrum goes to which part of the diagnostic coding might add some thoroughly confusing numbers. In short, I’ve no doubt the DSM-5 will win when it comes to sheer volume.

Allan Horwitz, Ph.D., is Dean for the Social and Behavioral Sciences, School of Arts and Sciences, Rutgers University, and Chair of the Mental Health Section of the American Sociological Association and of the Psychiatric Sociology Section of the Society for the Study of Social Problems.  He has written extensively on mental illness and its interaction with society–and has contributed via his articles to several different permutations of the DSM.

Dr. Horwitz, however, is unhappy. He doesn’t specifically kvetch about the increase in girth of the texts, but his piece alludes to how the uncontrolled growth  came about. I thank h-madness, a blog about the history of psychiatry, for providing access to Dr. Horwitz’s piece “DSM-V: Getting Closer to Pathologizing Everyone?”

It’s not long, and worth reading in its entirety, but just to pre-digest for you, in case you’re a world-class skimmer, as I can be:

Horwitz has several concerns about the process of compiling the manual, but focuses on the “three changes,  in particular, [that] could lead to an enormous pathologization of non-disordered conditions.”

Of course he addresses the removing the bereavement exclusion, which, as above, will fold bereavement into an Axis I disorder.

Concern 2 is more complex, but has profound implications for adding folks to the ranks of the mentally ill. The DSM-5 proposes adapting “dimensional assessments” for the existing diagnoses.

Up to this point, in using the DSM, to receive a diagnosis, the patient had to have, say, four out of 8 of the symptoms. That meant–and I wasn’t even that great at math, but I can follow–that if the patient had 3 of the symptoms, they did not have that disorder.  But what if the new DSM could create in approach in which the patient with 4 symptoms didn’t have that particular diagnosis, but rather some sub-version of it, thus having his own sub-disorder disorder? Horwitz is unimpressed by that possibility: “The current proposal to dimensionalize  measures of frequently occurring disorders threatens to  pathologize even mildly distressing conditions.” Seems he’d be a ‘3-strikes and your out’ kind of guy when it comes to diagnostic cutoffs.

And, finally, Horwitz is concerned about the new creation of “at-risk” categories for mental disorder.  This applies to people who have, say, just one symptom of a disorder–but whom the new text would encourage viewing as “at-risk” for a full-blown illness.

But, notes Horwitz, this “at-risk” allowance lets treaters diagnose people who are almost completely umsymptomatic as if they were in the early stages of an illness. There is no strong research indicating that someone who has one symptom of, say, bipolar disorder, is clearly in the early stages of the illness. Statistics seem to indicate that such a person has as good a chance of not becoming bipolar as of indeed developing the disease. It’s not a proposal he can buy into easily, without some serious limitations put on it.

He finishes his piece on what I can only call a down-note regarding the upcoming DSM-5 and its usefulness:

“The major proposals in the DSM-V . . . could wind up making psychiatry’s central  problem of distinguishing pathology from normality even more difficult  to resolve.”

And, hey, if we need more room for normality to become pathology–all bets are on that the DSM-5 will be bigger–although scarcely better, it unfortunately seems–than its forerunners.

Better start clearing a new place in my bookshelves now.

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