June 03, 2013

DSM-5: Pathologizing versus Dismissing

After years of working groups, expert task forces, and public opinion, the American Psychiatric Association has finally published the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM is the bible of mental illness, listing every diagnosable problem from autism to post-traumatic stress disorder to attention deficit/hyperactivity disorder to cocaine addiction. It's widely used by psychologists, psychiatrists, and general practitioners to categorize symptoms, differentiate between disorders, and communicate with other professionals.

Despite its widespread applications, use of the DSM is controversial because detractors fear that the manual pathologizes normal behaviour. This is a reasonable concern: for example, homosexuality was listed in the DSM up until 1986, an inclusion that effectively labelled homosexuals as mentally ill. Today, DSM-5 is criticized for new additions such as binge eating disorder, skin-picking disorder, and premenstrual dysphoric disorder (PMDD).

While concerns about pathologizing are legitimate, it's easy to go too far in the opposite direction and dismiss psychological problems that cause real and significant distress. For example, binge eating disorder (BED) is a controversial new diagnosis in DSM-5. It's the first time that binge eating has been recognized as a problem independently of more familiar eating disorders such as anorexia and bulimia. In his article about the 'worst changes in DSM-5,' psychiatrist Allen Frances dismissed the diagnosis of BED, attributing binge eating to gluttony and the wide availability of good-tasting food.

This is irritating. Not only is Frances' attitude flippant and dismissive, his statement ignores several of the diagnostic criteria for binge eating disorder. To be diagnosed with BED, you have to overeat at least once per week for a period of three months, but you also have to experience a lack of control over eating, marked feelings of distress, and three of the following: eating much more rapidly than normal; eating until uncomfortably full; eating large quantities when not physically hungry; eating alone out of embarrassment for overeating; and feeling disgusted, depressed, or guilty after binge eating.

The characterization of binge eating as gluttony or overindulgence doesn't account for the distress, isolation, and shame involved in BED. There's a difference between overeating with friends or family on a special occasion, and regularly standing in front of your fridge one hour after dinner, furtively shoving cold leftovers into your mouth and feeling helpless to stop. The criterion of 'distress or impairment in functioning' applies to most DSM diagnoses: scratching mosquito bites the week after camping is not the same thing as regularly picking at skin blemishes until they're bloody and infected (skin-picking disorder), and occasional tearfulness following ovulation is not the same thing as the monthly mood swings and deep sadness and despair that characterize PMDD.

While so-called fad diagnoses can divert attention and resources away from serious illnesses, and hastily slapping a diagnosis on anyone who reports a symptom now and then is obviously harmful, let's not go too far in the opposite direction, dismissing symptoms and denying treatment to people who are suffering. The changes introduced in DSM-5 mean that individuals who binge eat, pick their skin, or experience monthly episodes of distressing unstable mood post-ovulation may now have better luck convincing doctors that the problem is real, explaining themselves to loved ones, and getting their insurer to pay for treatment.

What's wrong with that?

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