Esteban Cardemil

As most folks with even a passing knowledge of psychiatry are well aware, the DSM-V was published this past month (May 2013) to considerable backlash. The arguments against the latest version of the DSM seem to boil down to two main concerns. First, there is concern that the sheer number of disorders as well as changes in some of the criteria will lead to a world in which everyone qualifies for one or more diagnoses. I am not troubled by this concern for a number of reasons, including my faith in clinicians’ general ability to distinguish clinically significant distress from not, my belief that it is worse to not diagnose people who are suffering than to incorrectly diagnose people who are not, and the possibility that all of this may bring psychiatry more into the mainstream society’s consciousness and reduce stigma. None of this is guaranteed, of course, but I am not particularly moved by this concern.

A much more nuanced criticism of the DSM, however has been recently raised by those who argue that the disorders described by the DSM are not real in any sense of the word and don’t necessarily map onto the underlying biochemical and genetic underpinnings of psychological dysfunction. This critique is much more serious, to my mind, and I agree with much of it. In particular, more people should know that the identification of discrete disorders came about as a combination of research review (good), political sensibilities (so-so), and pharmaceutical pressure (bad). Given all of the influences in the development of the DSM series, it would be surprising if the disorders mapped directly onto biological subsystems.

And yet, the assumption underlying this concern is seriously flawed: namely, that a disorder is only real if it can be directly tied to a genetic and biochemical marker and system. This argument conflates the concept of “brain” with “mind” and is grounded in a reductionistic, positivistic worldview that ignores the influence of society, culture, and individuality. Indeed, the most cutting edge research is recognizing that mental disorders (and NOT diseases, by the way), result from biological, psychological, and social influences. In the most simple biopsychosocial framework, biology plays an important role, but not the only role. And this second criticism of DSM stems from an assumption that a better diagnostic system would be more closely tied to biology. To my way of thinking, this approach is a long-term dead end, which hopefully will be avoided as more researchers expand their focus beyond the limited biological.