Bipolar Me

The Diagnostic and Statistical Manual of Mental Disorders (DSM) has gone through changes, and its creators are discussing further changes that need to be made. The DSM-V was updated in 2022 to produce the DSM-V-TR (Text Revision). The new set of changes may result in a DSM-VI. (That’s not an official name, but people are already referring to it that way.)

Over the years, the changes to the DSM have sometimes been made to address a better understanding of what constitutes a mental disorder. For example, homosexuality was listed in the original DSM (1952) as a “Sociopathic Personality Disturbance,” considered a “sexual deviation.” The definition was gradually chipped away according to societal pressure from advocates and a dawning realization that homosexuality was not a mental disorder. It wasn’t until 1987 that the diagnosis or versions of it were completely eliminated.

Autism took a similar path. In the 1952 edition of the manual, autism was categorized under “schizophrenic reaction (childhood type).” It was not recognized as a separate developmental diagnosis on a spectrum until the DSM-III in 1980. Schizophrenia has nothing to do with it, and the newer text reflects that understanding.

Rather than the be-all and end-all of psychiatric knowledge and diagnosis, the DSM-V is better understood as a guidebook that helps practitioners drill down through a puzzling array of symptoms to reach at least a preliminary diagnosis. While the publication date for the newest revision of the DSM is still up in the air, the fact that it needs updating is clear.

So, what changes are in store in the next edition? Well, for one, the American Psychiatric Association (APA) is changing the name of the manual to “Diagnostic Science (or Scientific) Manual of Mental Disorders.” That’s hardly a significant change, given that psychiatry is less of a science and more of a practice (or art). The committees of experts who are doing the revisions will be augmented by people who have lived experience of the various disorders and people who are critics of the current DSM—of which there are many. Among the criticisms is the fact that the manual pathologizes everyday events into psychological disorders. Children’s temper tantrums become Oppositional Defiant Disorder, for example. This medicalization of everyday behaviors may result in overdiagnosis, not to mention overmedication. And it’s particularly true that an ER doctor confronted with someone who has a mental disorder cannot, in the 15 minutes they’re able to spend with the person, tell whether their hallucinations are due to schizophrenia, bipolar 1, drugs, or some other cause.

The new DSM will reportedly change the way it defines diagnoses, from a reliance on symptoms and characteristics to include consideration of environmental, socioeconomic, cultural, developmental, and biological factors. For example, whether a person has experienced physical or sexual abuse in childhood will contribute to trauma diagnoses. It’s hoped that considering the whole person, not just their symptoms, will lead to a better understanding of psychiatric and psychological conditions.

Clarification of diagnoses to include new features or diagnostic criteria, however, can lead to oversimplification, something that will need to be considered in preparing the new edition. Biological features of disorders are supposed to be included, despite the fact that there are no objective tests, such as genetic tests or fMRI, to pinpoint a psychiatric diagnosis. This, of course, may necessitate further revision of the DSM as such testing improves. It’s hard to imagine how a discussion of future advances in diagnosis will help current practitioners until those advances are made. It’s an acknowledgment that even further revisions will ultimately be required.

The insurance industry will also be very interested in the new edition, whenever it comes out. In addition to definitions of the different conditions and lists of symptoms that can be used to make a diagnosis, the DSM also provides billing codes for the various disorders. And, as we know, getting insurance reimbursement for a particular diagnosis is difficult at best unless it has a billing code attached to it.

What the average patient will think about the updated DSM, if they know about it at all, remains to be seen. At any rate, it’s encouraging to think that the psychiatrists’ “Bible” may lead to more accurate diagnoses and better treatments. I just can’t shake the feeling that as soon as it is published, it will already be obsolete, needing ongoing tweaks that won’t be included until such time as another substantial revision is considered necessary. How long will we live with DSM-V (TR), essentially an unfinished work? I suppose at some point, the APA must decide when the DSM-VI, a work-in-progress, is “good enough” to publish.