Inside Story America

Redefining mental illness

As the new edition of an influential US psychiatry manual is released, we analyse its impact beyond clinical diagnosis.

The Diagnostic and Statistical Manual of Mental Disorders (DSM), known as the bible of psychiatry, is the most influential guide for helping doctors in the US define what a mental illness is.

Under the new guidelines a person who is grief-stricken after the death of someone close could be diagnosed with major depressive disorder.


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it’s not really a bible, it shouldn’t be worshipped.  It’s a guide, it’s mostly a guide to clinical care to help in deciding who has what disorder, and what’s the best treatment for it. Unfortunately [it] has been taken out of context, and used in many real life decisions often beyond the competence of the manual … so it’s moved out of the clinical arena … and now it has all sort of society influences often beyond its competence. “]

Elderly people who become forgetful but do not have dementia could be labelled as having minor neuro-cognitive disorder. And toddlers who throw tantrums could be diagnosed with disruptive mood dysregulation disorder.

Revisions like these have sparked a backlash among some respected psychiatrists in the US, who say the new guidelines are turning normal behaviour into illness, and will lead to the medication of patients that should not be.

The director of the National Institute of Mental Health issued a statement saying it was time to move away from the DSM-5 :

“The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure …. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever.”

But those who worked on the latest version of the DSM defend it as the “strongest science available” to help diagnose and treat those suffering from mental illness.

David Kupfer, the chairman of the committee that produced DSM-5, dismissed the criticisms of the manual as “A gross mischaracterisation of important changes instituted to help provide more precise diagnoses for people seeking help … DSM-5 is a guide book representing the strongest science available to help clinicians provide the best care possible for their patients”.

A study by professors from Harvard and Tufts universities published in March 2012 analysed the financial disclosures of 141 members of the work groups drafting the new psychiatry guide.

They found that 69 percent of the authors had ties to the pharmaceutical industry – that is a higher proportion than the 57 percent in the previous version of the book.

The study pointed out that the $10,000 annual limit on industry payments did not include research grants, and researchers also raised concerns about authors who serve with speakers’ bureaus, as experts paid to lecture about a drug company’s products.

So, is the DSM role being overstated and are patients being over diagnosed? What are the real boundaries of healthy mental behaviour? 

Inside Story Americas, with presenter Shihab Rattansi, discusses with guests: Dr Allen Frances, former chair of the psychiatry department at Duke University and author of the book Saving Normal; and Robert Whitaker, a journalist and author of the book Anatomy of an Epidemic.

” We’ve really been going down this particular diagnostic path since 1980, and that’s when the American Psychiatric Association published the third edition of its diagnostic and statistical manual and said we are going to make these constructs, and we are going to group together people by symptoms, and really the idea was that will help us research people with similar symptoms.” 

” But now here we are 30 years later, and the boundaries of mental illness have dramatically expanded so much so that in the United States, 20 percent of Americans now take a psychiatric drug on a daily basis, we have 11 percent of our youth diagnosed with ADHD, we … have this great expansion in bipolar diagnosis, and from a societal point of view rather than the burden on mental illness decreasing in these past 30 years, it’s greatly expanded in terms of the number people and disability … ” 

– Robert Whitaker, a journalist and author