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What DSM-5, Updated Mental Health ‘Bible,’ Means for Diagnosing Patients

May 20, 2013 at 12:00 AM EST
The American Psychiatric Association released a new edition of the DSM, which doctors use to diagnose and treat mental disorders. Judy Woodruff discusses the changes and implications for both patients and professionals with Dr. Michael First of Columbia University and Dr. Steven Hyman of the Broad Institute.
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JUDY WOODRUFF: Next: changes to the so-called “bible” of psychiatry and what it means for diagnosis and treatment.

This weekend, the American Psychiatric Association released a revision to the Diagnostic and Statistical Manual of Mental Disorders, often referred to as “the DSM.” It’s the first comprehensive update since 1994.

Doctors often utilize the DSM to diagnose mental illnesses. And there’s been much debate over the years about its role. We look at the changes to this manual now with two experts.

Dr. Michael First, he’s a psychiatrist at New York Presbyterian Hospital and a professor at Columbia University. And Dr. Steven Hyman, former director of the National Institute of Mental Health at NIH. He’s the director of the Stanley Center for Psychiatric Research at the Broad Institute.

Gentlemen, we welcome you both.

Dr. First, let me turn to you. Why is this updated diagnostic manual so important?

DR. MICHAEL FIRST, Columbia University: Well, the reason it’s so important is, the DSM is the guidebook that is used by all mental health professionals. It’s crucial to their ability to practice.

It defines all of the psychiatric diagnoses. And the psychiatric diagnosis, arriving at a correct psychiatric diagnosis is the first step in trying to pick the best treatment for patients. So, it is something that has enormous influence on everybody’s ability to provide the best treatment that’s possible.

JUDY WOODRUFF: Dr. Hyman, you have a somewhat different take on the value of it.

DR. STEVEN HYMAN, Broad Institute: Well, I think it’s critically important, as Dr. First said, for diagnosis and for insurance reimbursement.

But I think that the DSM is scientifically early. The brain gives up its secrets grudgingly. And we have to understand the DSM as a set of guidelines to diagnosis of often very serious disorders, but not as the bible of psychiatry. It is hardly meant to be by either the people who wrote it or in reality a perfect mirror of nature.

JUDY WOODRUFF: If it’s an imperfect thing, Dr. First, how does that affect what doctors can do and how patients are helped or not helped?

MICHAEL FIRST: Well, it’s imperfect mainly because our understanding of the core of how mental disorders, what’s behind mental disorders, remains — there’s a lot more to be understood.

And certainly, as we understand more over the years, our ability to provide the ultimately best treatment will continue to be improved. But what the book does now, it’s really a culmination of what we know about mental disorders. And that’s very, very helpful in being able to pick the right treatment.

So I agree with Dr. Hyman. It’s certainly not a bible. I think a better way to look at the DSM, it’s like a dictionary. It allows people to communicate. It allows mental health professionals to communicate with one another. It allows them to communicate with their patients. It allows us to communicate with administrators, so that we’re all talking about the same conditions.

It has its limits because our knowledge of the way mental disorders work has their limits.

JUDY WOODRUFF: Dr. Hyman, so how are patients affected by the changes in this new version of the manual?

STEVEN HYMAN: Well, I think the most important thing are patients. I mean, after all, diseases like schizophrenia, bipolar disorder, autism, depression, OCD — and I could go on — are the most disabling disorders in aggregate in the United States and cause enormous suffering.

It’s critical that doctors and in fact all mental health professionals have ways of matching patients with treatments, and also that the whole administrative apparatus around medicine has a way of reimbursing those things.

What the DSM does is to provide a shared language so that mental health professionals and patients and insurance companies know they’re talking about the same thing. And I think that is all well and good, as long as we don’t assume that every semicolon in the document is somehow rigidly guiding us.

And so, in the end, I hope that with this new revision and with — despite the controversies, that well-trained mental health professionals will still make sure that all patients in need of services get services. And I don’t really see anything in the revisions that should get in the way of that.

JUDY WOODRUFF: Well, that’s a question.

Dr. First, if — I mean, how much danger is there? Because there are some changes in here. For example, Asperger’s is I guess no longer in a separate category. It’s put under the heading of autism. But that’s just one of a number of modifications that were made. How do you see patients being affected by this?

MICHAEL FIRST: Well, the belief is, is that since the manual reflects the current science — and science continues to move along, perhaps slower than a lot of people would like it to, but there is still a continuing improvement in our description of mental disorders and our being able to — ability to be able to predict their course.

So the DSM will provide patients, as well as their clinicians, with the most up-to-date information to be able to provide help. Again, it’s far from perfect, but it’s still extremely useful. And it’s the best we have. And I think we have a lot to offer our patients, and the DSM is really the most up-to-date tool to provide that help to our patients.

JUDY WOODRUFF: But I heard Dr. Hyman say that if — if professionals interpret it too rigidly, that could be harmful.

MICHAEL FIRST: That’s true.

One of the rules on the front of the DSM that has been there actually since the beginning is — it says it very, very clearly. It’s not to be used as a cookbook. Clinical judgment — people go and learn how to be mental health professionals and spend years in practice gaining a skill. And that skill is the ability to use their clinical judgment in making decisions.

And that clinical judgment remains crucial. The DSM is part of the decision-making process for making a psychiatric diagnosis. And Dr. Hyman is actually — absolutely right. If somebody were to open up the book and just read the words and just apply them without using any clinical judgment, that could be very, very harmful. But that’s completely at odds with the way the book is supposed to be used.

And it says so in front of the book in plain language: This is not a cookbook. This must be used with clinical judgment.

JUDY WOODRUFF: Dr. Hyman, what about the use that insurance companies and others make, educational institutions make of this and how doctors use it?

STEVEN HYMAN: Well, I often say that doctors use the book, but just in the way that Dr. First said, with clinical judgment.

People who are insurance claims adjustors and educators and people in courts of law are not trained as clinicians and tend to read the book quite literally. And I think — I think it’s important that, with the revision, there be appropriate educational efforts again to make sure that nobody who really is in need of services is denied services or the book is taken to be too literal.

I think, given our current state of knowledge, there have to be compromises. And the book provides a way of communicating between clinicians and patients and people like insurance claims examiners. That said, I think the greatest problem with the book — and I think Dr. First and I agree with this — the people who should take it least literally are scientists, because you can get yourself into the fix that if you recognize that the book is imperfect, but you force yourself to follow every dictate quite literally, then you find yourself unable to make the very necessary progress that psychiatry needs.

Again, the brain is the most complicated organ in the history of human scientific endeavor. And we need to be able to approach it with an open mind.

JUDY WOODRUFF: Well, it is — it does offer some big changes. And we help — we thank you both for helping us at least understand a part of how it all works.

Dr. Michael First, Dr. Steven Hyman, we thank you both.

STEVEN HYMAN: A pleasure.

MICHAEL FIRST: Thank you.