The fourth edition (DSM-IV) was published in 1994, followed by a minor “text revision” (DSM-IV-TR) in 2000. Groups of psychiatrists are now drafting sections of DSM-V, due out in 2012.
It would be nice to imagine that the process of creating and updating DSM is scientific and unbiased. However, like laws and sausages, psychiatric nosology (disease classification) is more palatable the less one notices how it is made. As reported in today’s New York Times, putative disorders such as compulsive shopping, sexual fetishes, and binge eating have their advocates and detractors. Transgender people have a personal stake in whether “strong and persistent cross-gender identification” remains a mental disorder. (Interestingly, the stigma of this diagnosis is offset by its utility in obtaining insurance coverage for gender-reassignment surgery and other treatment.) This recalls debates over the inclusion of homosexuality as a mental disorder in earlier editions of DSM. Homosexuality was dropped as a diagnosis in 1973. It was replaced by “sexual orientation disturbance” and then “ego-dystonic homosexuality” before those, too, were dropped in 1987.
Anyone who imagines that these debates are coolly scientific is dreaming. As social norms change, our notions of mental illness change with them. The long-term trend has been an expansion of DSM, both in terms of dividing syndromes more finely, and also widening the scope of behaviors considered disordered. Stakeholders include the APA itself, sole publisher of the 800,000+ copies of this essential tome; pharmaceutical companies who stand to gain or lose fortunes based on whether a particular human deviance is treatable with medication; insurers who cover treatment for disorders but not non-disorders; patients who either have a mental illness or don’t; and scientists trying to collect data and make sense of the whole thing.
It is good to bear in mind that some disorders in DSM-IV-TR, like “nicotine dependence,” do not seem very much like mental disorders — and that one is bound to stay. Meanwhile, other maladies of the human spirit, like living a life devoid of meaning or purpose, are not listed in the current DSM, and are not likely to appear anytime soon. In my next post, I’ll discuss one aspect of psychiatric nosology, categorical versus dimensional ratings, that may improve DSM-V. However, the inclusion of messy social judgments in DSM is with us for the duration, obscured in the finished product by careful prose, numerical labels for disorders, and a little quantitative data. Laws and sausages aren’t bad either — if you don’t think about them too much.