July 8, 2013 | Posted By Jane Jankowski, LMSW, MS

The long awaited DSM-V was finally released for clinical use in May 2013, and was welcomed with a storm of debate. The task force charged with the revising the manual note that the manual had not been updated for 20 years and required revision to reflect changes in scientific knowledge and clinical experience in an ever shifting social context. Whether or not the DSM-V will alter clinical practice may depend on how the manual is viewed by practitioners. 

One possible benefit of expanding the list of diagnoses in a psychiatric manual includes improving recognition of problematic behavior health issues by insurance companies who fund treatment for diagnosable problems. Expanding the diagnostic options may enhance access to beneficial services for many, and this could prove helpful to those who might not otherwise receive treatment. Practitioners in the US know all too well that a diagnosis is needed if the provider is going to be paid by an insurance company. It remains to be seen if the changes in the DSM-V affect payment to providers.

One point to consider in the reimbursement argument is that a diagnosis is not necessary for treatment because those in desperate need are not turned away, though ongoing therapy may be hard to find with or without a diagnosis. The downside of expanding the various diagnostic categories is that people may be less likely to be held accountable for behavior negative or even legal consequences, notably changes in the paraphilia categories. We must be vigilant that mental health does not become misused as an excuse for antisocial, illegal, or dangerous behaviors where it is inappropriate to do so. 

For some, the controversy seems to boil down to a debate about how much of psychiatric illness is medical and how much is environmental for patients – the old nature vs. nurture debate. Some fear that new diagnostics have been defined by pharmaceuticals and that new disorders are soft on clinical evidence with the goal serving medication manufacturers rather than the best interests of patients. The reality seems to be that it is a blend of both, and the balance is different for any one patient. Some practitioners argue that early childhood experiences may trigger maladaptive behavior and relationship patterns resulting in clinically significant mental health problems. Others find that there are some symptoms that respond so well to medication there can be no doubt the problems are part of a chemical imbalance, and the medical model is appropriate. 

Diagnosing a mental illness is a clinical endeavor, that is, it is based on the clinician’s judgment. There are no blood tests, xrays, or other measures that give definitive results. Capturing the array of symptoms that affect patient behavior, thought, and sensory experiences is never going to be perfect but skilled clinicians are pretty good at it. We must be mindful of the real purpose of the manual; the DSM provides a set of guidelines for clinicians who must attempt to summarize each patient’s unique set of problems, it provides a shared language, and a set of best guesses as to what might alleviate the patient’s troubling symptoms. The DSM is a summary of disorders, not people, and is designed to be used by trained clinicians, not by the general public. The manual is only as useful as the skill with which it is used. What is considered normal, abnormal, healthy, or unhealthy in our evolving socio-cultural environment will continue to evolve regardless of what is written in the DSM-V, and we do not need to grant more power to a set of guidelines than was ever intended in the first place.  

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.
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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.