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Mind Games
Inside the controversial new f if th edition of the Diagnostic and Statistical Manual
of Mental Disorders
By Kwame McKenzie
April 17, 2013
Ayear ago, at the end of a University of Toronto lecture on mental health
promotion, I asked 400 medical students whether they would be content if
psychiatrists moved them f rom being distraught to a state of normal
unhappiness. My mentor had asked me the same question when I began my
training. T he concept of normal unhappiness helped me accept that things were not always going to go well,
and it also helped me understand my role as a psychiatrist: to intervene when time alone could not heal, and
when my patients and their f amilies or their communities could not cope. T his concept of normal unhappiness
has long been the standard in therapy courses, and I have raised it with my own students on and of f f or the
past twenty-f ive years. T hat day, though, it was on my mind f or other reasons.
T his month marks the publication of the f if th edition of the Diagnostic and Statistical Manual of Mental
Disorders, the bible psychiatrists use to diagnose mental illness. Since its inception in 1952, guidelines f or
diagnoses have become increasingly elaborate and controversial, and in the lead-up to the f if th version my
colleagues and I f ollowed the revision process closely. I knew that the proposed changes would likely increase
the statistics f or mental illnesses, yet again, and that this in turn might encroach on what we def ine as normal.
Problems my prof ession had previously considered part of everyday living could be reclassif ied as
pathological, and psychiatrists could be asked to treat issues previously thought to be outside our territory.
Even bef ore the release, criticisms f rom outside of and within the American Psychiatric Association, the
manuals publisher, were f ierce. DSM-5 workgroups have received over 13,000 comments and over 12,000
emails and letters since they started consultations in 2010. In June 2009, Allen Frances, chair of the task f orce
f or DSM-IV, suggested that the processes leading to DSM-5 were f lawed, and that they ran the risk of subtle
and dangerous unintended consequences such as new f alse epidemics. Worse, he continued, the work has
displayed an unhappy combination of soaring ambition and remarkably weak methodology.
External criticism came f rom the British Psychological Society and a powerf ul coalition led by a f action of the
American Psychological Association. In an October 2011 open letter to DSM-5, they argued that there was
insuf f icient empirical evidence to support the new manuals assertion that all mental disorders represent
underlying biological dysf unction. T he coalition also charged that proposed changes to certain DSM-5
disorder categories and to the general def inition of mental disorder subtly accentuate biological theory. In the
absence of compelling evidence, we are concerned that these reconceptualizations of mental disorder as
primarily medical phenomena may have scientif ic, socioeconomic, and f orensic consequences. T he f inal
consultation process only somewhat mollif ied the BPS: while some diagnoses were changed in response to
widespread censure, the association maintains that the guidelines lead to the risk of overdiagnosis and
thereby potentially unnecessary and potentially harmf ul treatment with medication.
Over-diagnosis is a real concern, and not limited to the new edition of the manual. According to the National
Comorbidity Survey Replication, the most comprehensive study of mental illness in the United States, about 26
percent of the American population would have had some sort of psychological disorder in the past twelve

months, if they were interviewed and diagnosed according to DSM-IV.


T he goal of each manual, of course, is to help prof essionals do their jobs, make diagnoses, and identif y
proper treatments. Historically, the authors have taken a utilitarian approach, characterizing a mental disorder
as a clinically signif icant behavioral or psychological syndrome or pattern that occurs in an individual and that
is associated with present distress or disability or with a signif icantly increased risk of suf f ering.
T his def inition presents two problems. T he f irst is that the onus is on the psychiatrist to f igure out where
normal human behaviour ends and pathological behaviour begins. If a woman chooses a string of unsuitable
partners and exhibits suf f ering and distress when each one leaves her, does her behaviour qualif y as
pathological? Does a child who cannot sit still in class, who is easily bored and becomes disruptive, have a
mental illness?
T he second issue is context. Disability is a possible criterion f or a diagnosis, but with the caveat that it ref lects
a problem of f unctioning. Whether or not someone has trouble f unctioning depends on what he or she is being
asked to do. If doctors rely on f unction to help them def ine mental illness, this could lead to two people with
the same symptoms receiving dif f erent diagnoses. A man who keeps to himself , has dif f iculty communicating
with new people, and cannot hold down a job because of this could be diagnosed with a mental illness. But the
same man might not be diagnosed if he were rich enough not to need a job. In the latter case, no clear problem
exists with f unctioning.
Psychiatric diagnoses are rarely objective: they are based on how doctors interpret what their patients say and
do. Psychiatrists interpretations can be inf luenced by many f actors, including their own drives and demons,
their peers, their patients, and the many policy-makers and businesses, especially the pharmaceutical industry,
that specialize in mental health issues. Changes in the way psychiatrists diagnose ref lect how they see the
world and what the world asks, or is happy, f or them to do.
T he increase in the number of DSM diagnoses may ref lect a larger shif t in societys expectations. Out of the
400 medical students at my lecture, only one considered it reasonable to expect psychiatrists to return
patients to a state of normal unhappiness. Everyone else thought we should strive f or more. T his suggests
that the psychiatrists and psychologists who created the manual, as well as the North American society they
serve, now expect to achieve something other than normal unhappiness. It also raises questions: If
unhappiness causes distress and people do not want to be unhappy, does this make unhappiness an illness?
And should the pragmatic DSM-5 of f er guidance to prof essionals about how to diagnose and treat people who
want to be happier?
T hree major systems are used to make mental health diagnoses: International Classification of Diseases,
published by the World Health Organization (and used by more prof essionals in more countries); DSM, the
primary source in the US and Canada; and Chinese Classification of Mental Disorders, in part a hybrid of the
other two but with culture-specif ic diagnoses. Because DSM is rule baseddoctors make a diagnosis if the
patient has certain symptomsit is of ten pref erred by researchers, pharmaceutical companies, regulatory
bodies, and health insurers.
T he f irst of f icial classif ication system in the US was developed f or the 1840 national census. Governments
around the world had started to take responsibility f or mentally ill people, and states were building huge
hospitals. Getting a handle on the possible volume and cost of this enterprise was important. T he American
government was not interested in complex ideas of the psyche or symptoms of depression. It was only
interested in f inding out who could not f unction in society and who might need looking af ter. To that end, there
was only one category to choose f rom: idiocy/insanity.
By 1917, with mental hospitals f ull, the National Commission on Mental Hygiene and a f orerunner of the
American Psychological Association decided that a more detailed diagnostic system would prove helpf ul in

deciding which hospital patients needed what kind of treatment. So they developed the Statistical Manual for the
Use of Institutions for the Insane, which contained twenty-two diagnoses.
T he development of psychiatry in Canada f ollowed an almost identical trajectory, not least because major
f igures such as Dr. Clarence Hincks, who is credited with co-f ounding the Canadian Mental Health Association,
worked at the national level in both Canada and the US throughout the f irst half of the twentieth century.
A major issue in North America was how to treat the large numbers of soldiers who had suf f ered shell shock
during World War I. Having developed the necessary expertise, US psychiatrists later became involved in
recruiting American soldiers f or World War II. It was hoped that a more detailed assessment and
characterization of their psychology would help to identif y those who were unlikely to survive the rigours of
war. A new diagnostic system, Medical 203, was published in 1943 and adopted by the US armed f orces and the
Veterans Administration.
T he game changer came f ive years later. Previously, International Classification of Diseases had categorized
only physical illnesses, but in 1948 it added a section on mental disorders, which could be used to diagnose
anybody, not just those in institutions or the military. Rather than accept the ICD system, though, the US
decided to def ine the mind f or itself . In 1952, the APA produced an adapted version of Medical 203, the original
Diagnostic and Statistical Manual of Mental Disorders.
DSM-I listed ninety-f ive mental disorders. DSM-II was published sixteen years later with 130. Both editions were
based on the theories of Sigmund Freud and other therapists who believed that present behaviours were
caused by the mind trying to resolve problems f rom the past. T he symptoms that constituted a disorder were
not described in detail, and the manuals diagnoses remained subjective. It soon got into trouble.
In 1971, a major international study attempted to measure the rate of schizophrenia in the UK and the US, and
it showed that diagnosis rates were much higher in the US. Scandal f ollowed in 1973, when American
psychologist David Rosenhan published On Being Sane in Insane Places in the journal Science. He had sent
eight healthy people to gain admission to twelve dif f erent American psychiatric hospitals by saying they heard
voices. Once admitted, they acted normal and exhibited no symptoms. None of the hospitals detected the f ake
patients. All were diagnosed with a mental illness and were prescribed various medications as a condition of
their release, even though they had presented identical symptoms.
Such challenges f orced another rethinking of the manual, and the 1980 DSM-III aimed to improve the unif ormity
and validity of psychiatric diagnosis, and to sort out the problem of over-diagnosis of schizophrenia. T heories
of pathology based on the thinking of therapists such as Freud were abandoned. Diagnosis was made on
symptoms alone, and these were now more clearly def ined. T he book ballooned to 494 pages and listed 188
diagnostic categories; a 1987 revision, DSM-IIIR, grew to 567 pages and 215 diagnoses. But the new approach
carried its own set of problems, and the chair of the DSM-III committee later criticized his own methods, saying
that they had led to the medicalization of 20 to 30 percent of the population, who may not have had any
serious mental problems.
In 1994, the APA decided it was time f or a new, bigger edition (886 pages, 283 diagnoses) and an approach that
considered more than just symptoms. DSM-IV advised psychiatrists f or the f irst time to ref rain f rom diagnosing
an illness unless symptoms caused clinically signif icant distress or impairment in social, occupational, or other
important areas of f unctioning. By allowing clinicians to rely more heavily on their judgment, the new
methodology encouraged a more subjective interpretation of textbook illnesses. It also caused conf usion,
because equally severe symptoms may be more upsetting to some people than to others, but only the person
who is distressed gets a diagnosis.
Identif ying and def ining mental illness has always been f raught. T hough medical conditions may ref lect discrete
problems with clear pathology, psychiatric conditions can ref lect many underlying issues. Putting them together

and saying they constitute an illness only works if there is pathology to back it up, but the pathology of mental
illnesses is not so clear cut. Medical science may work well f or illnesses of the brain, where doctors can
identif y lesions that are causing specif ic symptoms, but not f or illnesses of the mind, where of ten they cannot.
And even if they could link pathology to symptoms of the mind, we would still have a problem, because
diagnoses are not based on symptoms alone, but on the impact those symptoms have on how a person
f unctions in the world. Reducing humans and human behaviour to symptoms without considering the
complexities of existenceand the f act that we are past, present, and f uture beings with a social and
historical contextmay never produce a satisf ying system f or understanding mental problems.
When I trained back in the late 1980s, I was taught that psychiatry had little place in the grieving process unless
the person was dangerously ill or suicidal. It was ill advised to prescribe tranquilizers, because they interf ered
with natural processes in the body and the mind f or dealing with traumatic events. It also undermined the role
of f amily and community in helping people through dif f icult times.
We were taught to ref er the person to a grief counsellor and to only consider intervention f or complicated or
prolonged grief . If the person was still in bad shape at six months, then we would consider stepping in. T he
1994 DSM-IV delivered a dif f erent message: the new cut-of f f or abnormal grief was two months. Now DSM-5
proposes that psychiatrists diagnose depression right af ter bereavement and of f er drug treatment to those
who are grieving and depressed. To meet the guidelines f or any f orm of major depression, a patient need only
exhibit symptoms f or two weeks.
One member of a DSM-5 workgroup, Kenneth Kendler, has argued that bereavement is simply a negative lif e
event. He suggests that people are resilient, and that f or most of them major negative lif e events do not lead
to depression, although in some they do. Depression af ter bereavement or job loss looks the same, so it
makes sense to diagnose and treat it in those who are grieving.
But this argument misses a key point. Grieving is a personal and social process that ref lects both how we deal
with mortality and the way we demonstrate the bonds between us. Depression is part of the grieving process,
a part of letting go as well as paying ones respects. T he emotions may look the same, but the context and the
meaning may be dif f erent f rom a response to the loss of a job. What would it say about where we are as a
society if people did not expect to be upset and depressed af ter the death of a loved one?
Its not that people dont expect to be distressed or even depressed, but that many think society will not wait
f or them to heal. T hey do not want to hold back a high-perf orming team. T hey complain that they do not have
proper coverage in their jobs or their medical insurance f or grief . T hey cannot af f ord the time of f work, or they
have little social support and so are open to pharmacological assistance. Others say that in a tight market they
f ear what will happen to their jobs if they take a prolonged leave.
Such expectations may say more about our culture than about the experts who developed DSM-5 or the
psychiatrists who will use it. As one colleague has remarked, Which doctor these days is going to say to
someone who is depressed, grieving, and asking f or antidepressants, Go of f and be distressed. It will be good
f or you?
T he British Psychological Society has criticized DSM-5 f or being clearly based largely on social norms, with
symptoms that all rely on subjective judgements not value-f ree, but rather ref lect[ing] current normative
social expectations. It has also expressed a major concern that clients and the general public are negatively
af f ected by the continued and continuous medicalisation of their natural and normal responses to their
experiences which demand helping responses, but which do not ref lect illnesses so much as normal
individual variation.
Derek Summerf ield, a renowned British psychiatrist who researches post-traumatic stress disorder around the
world, questions the usef ulness of sending in trained counsellors to diagnose and treat disaster victims, a

practice he links to the guidelines set out in international classif ication systems such as DSM. PT SD f irst
entered the manual as a concept in 1980. In a 2001 British Medical Journal article, he contended that labelling
people with PT SD may do more harm than good: To conf late normality and pathology devalues the currency of
true illness, promotes abnormal illness behaviour, and incurs unnecessary public costs. He argued that when
people are expected to cope, they build resilience: treating them as medicalised victims instead of f eisty
survivors could undermine their skills to help themselves and others. Maybe we are relying too heavily on
therapists to help f ix what is, at bottom, a problem better addressed in a social context.
Historically, the DSM system has f ocused on the individual when much of the evidence points to the need f or
better understanding of the social f orces that cause us dif f iculty and shape our world. T hat shaping of the
world includes what the prof essionals consider a diagnosis, and what we expect our governments and doctors
to do f or us. If we believe that people have the right to not suf f erthe f lip side of the right to pursue
happinesswe need to have a discussion about the best way to achieve that. Do we want to promote a
society that can support people psychologically, or do we want to continue the process of diagnosing and
treating the problems manif ested in individuals?
T here is some indication that the manual may sof ten its emphasis on the individual. T he previous edition
introduced the concept of relational problems, not as a f ull-f ledged diagnosis, but as a contributing f actor to
it. In 2002, a research agenda f or DSM-5 proposed adding relational disorders as a primary diagnosis to help
therapists identif y persistent and painf ul patterns of f eelings, behavior, and perceptions involving two or more
partners in an important personal relationship. Rather than blaming either party f or the problem, the aim is to
examine the relationship between the two and consider what could be done about it. Over the past ten years, a
task f orce has pushed to include relational disorders in both the new DSM and the next revision of
International Classification of Diseases. To that end, it has sponsored two national conf erences and published
two books. Relational disorders did not make the cut f or DSM-5, but the new def inition of relational problems
is f ar more in-depth and precise than the previous version, and the task f orce hopes to include the new
diagnosis in the next edition. T his would mark a revolutionary shif t away f rom the manuals preoccupation with
the individual.
If our minds are engaged in a relationship with the world, then mental illness is the f ault of neither. It is the
relationship between them that is problematic. Instead of f ocusing on one or the other, we should spend more
time considering the interaction between the two and what can be done about it. T he new DSM may help
psychiatrists f ormulate more accurate diagnoses, but I worry that its f ocus on the individual may detract f rom a
wider investigation into the issues. It pushes us toward labelling and blaming people f or reactions to the
situations they f ind themselves in, rather than helping us to understand the many f actors that can contribute
to mental illness. We need to understand both the individual and the environment, and how they interact, if we
are truly going to improve the worlds mental health.
Kwame McKenzie is medical director of access and transitions at the Centre f or Addiction and Mental Health in
Toronto.
Tamara Shopsin and Jason Fulf ord collaborated on the new memoir Mumbai New York Scranton.

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