Matters come to a head

The revision of the psychiatrists diagnostic bible is stirring a hornet's nest as usual.

In the world of medical literature, it is one of the most anticipated events. So eager, in fact, that the very mention of commencement of work on it kicks up a storm. Some of America’s top psychiatrists have gone into a huddle to come up with the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Published by the American Psychiatry Association, it is said to be the final word to assess and treat mental disorders in the United States and the world. Also, it is a critical reference document for clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies and policy makers.

If you want that in numbers, the last revision in 2000 was purchased and read by an estimated half-a-million people. This time around expectations are equally high and the edition has to deal with a host of contemporary mental disorders.

With more than a decade-and-a-half passing since the last revision, the problems seem to get even more befuddling. The professors — numbering 28 — who are involved in consultations have to decide on issues that have continued to surface due to rapid lifestyle changes in the period.

They have to figure out if, for instance, compulsive shopping is a mental problem? And what about people’s different fetishes? The answers, it is said, will define new research, insurance reimbursement and even individual psychological profiling. This is the book which enshrined terms such as Obsessive Compulsive Disorder (OCD).

There are a total of 283 disorders described in the DSM and updating that will involve meeting with sample groups associated with the new issues. A series of meetings, closed to the outside world, will make the final editorial changes. It is said that to ensure that the panellists are not influenced by pharma companies they, “agree to limit their income from drug makers and other sources to $10,000 a year for the duration of the job”.

The prickliest issue still remains how to incorporate gender issues in DSM. Protests by gay activists in 1973 induced a review where homosexuality was dropped from the diagnosis. It was replaced by “sexual orientation disturbance” and then “ego-dystonic homosexuality” before being dropped again in 1987. This time, panellists haven’t offered any stance.

The DSM is not without critics though. Edward Shorter, author of the best-selling book on the history of psychiatry, Before Prozac, is a noted critic. He says: “In psychiatry no one knows the causes of anything, so classification can be driven by all sorts of factors — political, social and financial.”