Although it is billed as the fifth edition, any normal non-psychiatrist would call this the seventh, with a long back history behind it. Following earlier attempts by the US Census authorities, the American Medico-Psychological Association, as it then was, produced a brief statistical breakdown of mental disorders in 1917. After changing its name to the American Psychiatric Association (APA) it produced a new classified list which was eventually incorporated into the American Medical Association's Standard Classified Nomenclature of Disease. There is also an international classification of diseases: in 1900 an international congress started publishing the International Classification of Causes of Death, which was revised every ten years until 1949 when publication of the sixth edition was taken over by the World Health Organization and the title changed to International Classification of Disease (ICD-6). In 1952 the American Psychiatric Association extracted and amended the sections of ICD-6 relating to mental disorders, to produce a pamphlet-sized Diagnostic and Statistical Manual – DSM-I. This was eventually revised as DSM-II in 1968, still only 130 pages long and small enough to tuck unobtrusively into the pocket of a white coat.
Work on DSM-III commenced following the publication of ICD-9. DSM-III took a radically different approach, producing a multi-axial classification rather than a straightforward listing. Students of library history will notice a startling similarity to Ranganathan's theories, as outlined in the Prolegomenon to Library Classification. I do not know whether the APA team knew of Ranganathan, but the resemblance is there.
From the moment of publication it was clear that there were major problems with implementing DSM-III. Even the chairman of the committee which produced it was severely critical. For various reasons, rather than call for a new edition, the text was radically re-written as a “revised version” – DSM-III-R. Surprisingly this happened again with the fourth edition: DSM-IV followed the 1992 publication of ICD-10, was found to be unworkable in various ways, and, rather than produce a new edition, was revised as a “text revision” – DSM-IV-TR, in 2000. Now we have a fifth edition, DSM-5 (they seem to have dropped the Roman numerals). I wonder what they will call the revised version when they find that this one does not work properly either?
There have already been some very stern criticisms. The chairman of the committee which prepared DSM-IV says “DSM-5 suffers from the unfortunate combination of unrealistically lofty ambitions and sloppy methodology […] the sad result is a manual that is not safe and not scientifically sound” (Frances, 2013).
Unfortunately DSM does not represent a happy consensus. There is wide disagreement among psychiatrists as to the validity of all but the most basic classification. You cannot now find physicians who claim that measles and mumps are aspects of the same disease, or surgeons who say that having a broken leg is one aspect of the Not-Being-Able-To-Walk syndrome, but I can easily find you highly respected psychiatrists who hold parallel views. The medieval classification of mental disorders into “lunacy” (the psychoses), “idiocy” (learning disorders), “palsy” (neurological disorders) and “hysteria” (the neuroses) probably still holds good (Guha, 2010) but any more detailed subdivisions are controversial. There are no biological tests to “prove” that someone has, say, bipolar disorder: it has to be a matter of definition rather than proof. All mental disorders cover a spectrum from mild disturbance to life-threatening malfunction, and, again, there is no “proof” of where any person lies on the spectrum, it has to be a matter of definition.
The real problem is that, although DSM started as a clinical manual to help psychiatrists to diagnose and care for their patients, it is now largely designed to support two extremely influential commercial groups which are not directly involved with patient care. On one hand, medical treatment in America is based on health insurance. It is not enough to have a clearly visibly ill patient in front of you. The psychiatrist must ensure that the patient fits a precise definition of illness, otherwise he will not get paid. There is no laboratory test to prove that a patient has a psychiatric disorder. Insurance companies will always, invariably, wriggle out of paying if they can, so very clear criteria have to be spelled out – a patient who only ticks 13 out of 14 boxes may not have their treatment paid for.
On the other hand, there are the pharmaceutical companies. The pressure put on psychiatrists by the drug companies has to be seen to be believed – even after having observed it at close hand for years I am still sometimes staggered. We have now reached the stage where some 20 percent of Americans are currently taking a prescribed psychotropic drug, and the incidence of overdoses with legal drugs is greater than that of overdoses with illegal ones (Centers for Disease Control and Prevention, 2011). If one in five Americans was mentally ill by DSM-IV-TR standards, it is predicted that the proportion will rise to about one-third under DSM-5, with, surprise, surprise, a drug treatment available for every disease entity listed. The solution, it seems to me, is to extend the process until it covers 100 percent of us, then rename the book The Diagnostic and Statistical Manual of the Normal Human Condition. On present trends they will reach that stage by DSM-7.
In the mean time we have this huge slab of a book – definitely a desk reference tool rather than something to slip into a white coat pocket. DSM is sometimes referred to as “the psychiatrist's bible”. It should perhaps be borne in mind that the Bible is the book which contains at least two contradictory creation stories, instructs us never to eat oysters, says that all debts (including mortgages) should be cancelled after seven years, and warns us that God will be extremely upset if you cook a baby goat in its mother's milk. There is a great deal of useful teaching in DSM. A lot of sincere and conscientious work has gone into its descriptions and definitions. Although produced by the APA it is used world-wide: psychiatry has become Americanised (Guha, 2012). All medical libraries will need to buy this and should consider some of the guidebooks to it which have already started to appear – Nussbaum (2013), Paris (2013), Frances (2013), Black and Grant (2014) for example. There is a wide public interest in mental disorder, and a sometimes justifiable public distrust of psychiatric diagnosis. Public reference libraries may therefore need to offer their readers access to it, and should discard all earlier editions. No-one should ever use it as a straightforward diagnostic tool.
