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The boy scout guide to mental illness


DSM-5 coverMental health is big business — very big business. I know — I'm an active client of the industry.

Mental health thrives on a classification system spelt out in the Diagnostic and Statistical Manual, now in its fifth edition (DSM5). Unlike guides to diagnosis in other specialties, the DSM5 is completely focused on the symptoms experienced by the patient — two people could have a consultation with a psychiatrist and be diagnosed with precisely the same illness, irrespective of whether the underlying causes of their illness were poles apart.

As a handbook for clustering like symptoms with like symptoms, the DSM5 is unrivalled. As a manual that gives us insight into the etiology of specific mental illnesses the manual is severely underdone.

What is amazing is that few among the experts seem nonplussed about this. The DSM5, introduced earlier this year, is primarily a diagnostic tool to ensure that like is treated as like, at least when it comes to symptoms. This is a critical part of the legitimacy of the psychiatric profession — we can't have psychiatrists disagreeing all the time on what illness a patient suffers — as well as being the bible for determining the appropriate bounds of medicinal, speaking therapy and other interventions.

In the 1970s the DSM listed homosexuality as a mental illness — something that both much of the research community and all the gay community disagreed with. In the stroke of an editorial pen hundreds of thousands, perhaps millions, were cured by the declassification of homosexuality as an illness in the DSM. The DSM is a socially constructed manual, put together by those with a vested interest in mental health.

But what of the current DSM? Asperger's syndrome no longer exists, but is part of a spectrum of autism. Depression is expanded to include those down in the dumps for an extended time because of a death of a loved one. This is by and large good news for anyone who wants to match a client with a treatment — don't be too fazed by what is going on, simply look at the symptoms, get a classification and treat accordingly.

The truth is that our society is amazingly ignorant of the underlying causes of mental illness, and would seem not too interested in finding out more. I've been diagnosed with a major depressive disorder, melancholia — you can find it in the DSM. But my treating psychiatrist and I work together to find treatments — mostly drugs — to keep me in the realm of the sane. And it works about half of the time.

If the DSM came up with another name for my illness, I doubt that my consulting specialist would change course much. If pharmacological firms came up with a different treatment, that might be a different matter.

It is hard to get away from the idea that the DSM5 and its predecessors are driving the medical health agenda. They are the bible and the faithful shall follow accordingly. But better skilled physicians can take the DSM for what it is — a useful but limited taxonomy seeking to group like symptoms with like.

There are two paths out of this impasse. The first is to insist on a DSM based on more than symptoms, on the underlying causes of mental illness. Given the state of knowledge, this is not likely to happen in my lifetime. The second is to have medical practitioners use the DSM for what it is — a boy scout guide to psychiatric illness — and use their professional judgment to play around on the boundaries of what might and might not work as a treatment.

Sadly, GPs by and large are not trained in this field of endeavor. Most rely on the imparted wisdom of the DSM, while psychiatrists present a broad field of those who faithfully follow the DSM and others, like mine, who use it as a rough and ready guide before getting down to the serious business of trying to understand what is going on in my head that makes me fit a category in the DSM5.

My best guess is that the DSM will phase through versions 6, 7 and 8 at the minimum before etiology precedes symptoms as the defining characteristic of illness. In the meantime we can complain about the deficiencies of this diagnostic tool, or seek out and support those physicians who see the DSM for what it is — a ready reckoner to get the ball rolling, but not the last word on mental illness.

Michael Lockwood headshotMichael Lockwood is an ex-senior public servant and consultant who has worked for state, federal and local governments. He is currently exploring a range of projects including other peoples's stories about depression. To find out more visit PortraitsInBlue.com. Michael thanks his colleague, Viv Read, for the support she gave him in drafting this article.

This week is Mental Health Week

Topic tags: Michael Lockwood, DSM5, mental illness, health care, depression



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Existing comments

Ascribing biblical status to manuals will always be problematic as you point out Michael. Culturally, the confusion starts with those constructing the range of manuals, whose product really is a, "socially constructed manual, put together by those with a vested interest" in their subject. The Bible, on the other hand, allows for what you recommend concerning a manual for mental health, "based on more than symptoms, on the underlying causes" with over two thousand years of discussions, arguments, but still revered as God's Word 'living and active as a two edged sword, cutting to the marrow'. Your present predicament of being beholden to the DSM5 with regards to your illness is similar to when some people only take the Bible as a history or for only those who 'fit in' to its contextual criteria. I sense in your journey with your mental incapacity, the desire to find a Biblical pathway through the challenge, but sadly, the DSM5 takes you and your illness only in the context of how the present treatments are understood by their promotors. Maybe No 6 will recognise, appraise and promote the supernatural context for mental incapacity, health and treatment.

Fr Mick Mac Andrew | 10 October 2013  

A very interesting read and so true. A book which addresses the history, development of and use of DSM5 called Saving Normal by Allen Frances M D is very relevant for those dealing with mental health issues. Good Luck!

Judy Lawson | 10 October 2013  

I think that mental illness is poorly named. It is not the mind as such which is ill. Or the brain. It is the person who feels ill and discomfort or pain, much as one does with physical illness. And the DSM approach has at least one benefit identified by Michael....it focuses on symptoms not theory. I certainly agree that DSM is not the last word. But it is useful in its focus upon what the person is experiencing, not on some theory of the self which may or may not fit the person in pain.

Tony Macklin | 10 October 2013  

Thanks, Michael. Gordon Parker the former Executive Director of the Black Dog Institute and fomer Head, School of Psychiatry, University of New South Wales for 20 years has written about earlier editions of DSM. In his latest book called "A Piece of My Mind" he expresses similar criticisms of the DSM. You can listen to a podcast of Margaret Throsby's interview of him last year from the ABc's website.

Kim Chen | 10 October 2013  

For so long the DSM has been the go to source for diagnosing "mental illness". I believe it would be hard pressed to find a person who doesn't at least exhibit some symptoms of a disorder described in the manual. What is stand out to me is that the manual has continued to grow since it's inception. Every year more items are added. I agree, that there is hardly any investigation on the causes of these 'illnesses'. I remember when I was in hospital, and I have been there a few times, there was not talk about my world view, or family situation or anything more than the 'fact' pertinent to the diagnosis. As a guide, yes it does serve a purpose, if not just to educate people about what could be expected or what someone may be experiencing. However as a 'bible' it's far from the ideal. I do hope there is more investigation about the other causal possibilities that interlink with 'mental illness', there are so many other dimensions like: physical health, spiritual beliefs and the boundless unknown potential of the human mind. We've come a long way since the days of lobotomies, and there is a long way to go, I hope that we continue to head in the right direction.

Jen | 10 October 2013  

Michael I like your description of the DSM as a boy scout guide to mental illness. It caused me to reflect on the time when I worked as an allied health clinician in mental health and the DSM was held up even then as the be all and end all of determining the so called problem. I ran into many a conflict arguing that we would be better to understand the underlying symptoms and causation and the person themselves rather than relying on the definitive word. The project Portraits in Blue www.portraitsinblue.com is attempting to do this through the collection of narrative from those who experience depression, those who know someone with depression and those who work with people with depression. It is attempting to understand the person rather than the definitive definition. I would encourage people to contribute.

Laurel Sutton | 13 October 2013  

Re DSM V as scout or even seminary manual: "In DSM V Pedophilia is termed pedophilic disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and the manual defines it as a paraphilia in which adults or adolescents 16 years of age or older have intense and recurrent sexual urges towards and fantasies about prepubescent children that they have either acted on or which cause them distress or interpersonal difficulty.[1]"[Wiki] Frankly even if a seminarian had not acted on such recurrent urges in him and felt no distress re urges-he ought be shown the front door asap methinks!

Father John George | 13 October 2013  

Father George You've struck at the heart of one of the dilemmas facing mental illness - when is it a sin and when it is the outcome of an illness over which the perpetrator has no or little control? Your pedophilic seminarians should exit their Ministry, but what happens to them next? The trouble with mental illness is that it can span the barrier between illness and criminality - and often the boundaries are blurred. Me thinks that that once leaving the seminary they should be offered psychiatric assistance, not that it will necessarily make a difference.

Michael Lockwood | 18 October 2013  

In line with DSM-5, if the aforementioned exit-sem hasn't acted out pedophilia and relates well generally and not bothered by recurrent pedophilic erotic urges, then in 'DSM-think' no need to follow up after sem exit. DSM 5 doesn't categorise him as having pedophilia disorder, in fact, DSM regards him at worse as an innocuous paraphiliac. Sexologist John Money marketed the "paraphiliac" as a "non pejorative classification for unusual sexual interests". He described paraphilia as "a sexuoerotic embellishment of, or alternative to the official, ideological benchmark.[charming!]
Frankly, disregard DSM! such "exit sems" ought be carefully kept track of plus behaviour therapy if possible, etc. Methinks further, DSM has become a plaything of sociological political correctness gone overboard from 197S onwards.

Father John George | 20 October 2013  

Regarding etiology,there are as many etiologies I suggest as there are schools of psychology,psyhiatry,psychobiology,genetics,DNA biochemistry etc [Meanwhile the Freudian psychoanalytic approach, has been long debunked by Hans Eysenck, a British psychologist (born in Germany) noted for his theories of intelligence and personality, and for his strong criticism of Freudian psychoanalysis, in his "Decline and Fall of the Freudian Empire"[1985]. The issue of moral freedom and sin is located,I suggest, in the prior decision to enter the proximate occasion of sin well before 'in actu flagrante'

Father John George | 21 October 2013  

Laurel Sutton it is of note that beside the highly descriptive topographical DSM genre, hopefully there will also develop supplementary studies that ex professo flesh out DSMs Thus fir starters "Dr. Sperry helps provide the reader with an understanding of the underlying sources and treatment implications of these disorders. The book will certainly assist those with considerable clinical experience, but it will be especially appreciated by beginners who will soon be introduced to clinical work with these problematic patients. This text assists the novice clinician every step along the way, from initial diagnostic contact to final treatment evaluation. SPERRY, LEN (2007-03-16). Handbook of Diagnosis and Treatment of DSM-IV Personality Disorders . Taylor & Francis. Kindle Edition. .

Father John George | 26 October 2013  

The American Psychiatric Association has backtracked.
In its newly published Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), APA “changed the classification of pedophilia from a ‘disorder’ to a ‘sexual orientation,’ but, following the public outcry, APA released a statement that it was a mistake.”[FoxNation[

Fr John M George | 04 November 2013  

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