The mind, in our modern conception, is an array of circuits we can manipulate with chemicals to ease, if not cure, depression, anxiety and other disorders. Drugs like Prozac have transformed how we respond to mental illness. But while this revolution has reshaped treatments, it hasn't done much to help us diagnose what's wrong to begin with. Instead of ordering lab tests, psychiatrists usually have to size up people using subjective descriptions of the healthy vs. the afflicted.
Which is why the revision of a single book is roiling the world of mental health, pitting psychiatrists against one another in bitter debates. The book is the Diagnostic and Statistical Manual of Mental Disorders, or DSM for short, and it is the bible of mental illness. First published in 1952, the DSM attempts to catalog every psychological problem humans experience. The new edition set to be published next year will be the first revision since 2000. It will literally redefine what's normal.
On any given day, 4.4 million Americans receive mental-health services. Patients, doctors, insurers, pharmaceutical companies and taxpayers all have a stake in how the new edition is written. For anyone feeling down or anxious, tweaks to the DSM may determine whether their symptoms are merely unpleasant or actually signs of disease. These changes will ripple through the mental-health field and affect whether and how much insurers will pay for treatment. Small wonder, then, that the production of what's being called DSM 5 is wildly controversial.
Some of the most heated disputes revolve around how to diagnose well-known disorders. DSM contributors have proposed rewriting the definitions of autism, depression and schizophrenia, among others. Autism would become part of a "spectrum" of disorders including milder social-interaction problems like Asperger's syndrome. That proposal has angered advocates for the autistic, who fear the changes could obscure the reality that some autism patients need lifetime supervision. The new definition of depression would eliminate a current exception for bereavement, meaning those mourning the loss of a loved one could be diagnosed with an illness. The American Psychiatric Association (APA) has proposed adding binge-eating disorder, though it would be defined, in part, with an imprecision bordering on absurdity: eating "an amount of food that is definitely larger than most people would eat."
Even as these arguments rage, science is making progress in unraveling what makes the mind go awry. Magnetic-imaging technology has shown that, for instance, when we are scared and anxious, the neurons in a brain region called the amygdala light up. But clinically speaking, when a patient is in front of a desk, that knowledge matters little in whether a psychiatrist can diagnose anxiety disorder. Dr. David Kupfer, the genial University of Pittsburgh professor who chairs the DSM revision, says that although genetics and neuroscience have offered powerful insights into how mental illness begins, the research hasn't advanced enough for use as a diagnostic tool. "I can't do neuroimaging in my office," he says. "We are lacking the validation of these methods, which are promising but not decisive." In simpler terms, mental-health diagnosis remains as much art as science.
A Guidebook for the Mind