Peter Reiner of the Neuroethics & Law Blog points to the impending arrival of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or as it will be commonly known, the DSM-V.  DSM, in its various editions, is generally treated as the bible of psychiatry, providing diagnostic criteria for a host of mental maladies from the common, such as depression, to the bizarre, such as trichotillomania.

Readers of this site may know that the DSM is relevant to a number of fields of legal practice, including criminal law, tort practice, workers compensation, and increasingly employment law.  If nothing else DSM often provides fodder for cross examination of experts, but in some cases it interacts with the law more directly.  For instance, whether a person is psychiatrically “disabled” within the meaning of the Americans With Disabilities Act, or an insurance policy, may turn on whether that person’s problems can be summarized through a DSM diagnosis.  Revisions to past editions of DSM have even had social and political ramifications in the culture at large.  Arguably the removal of “homosexuality” as a form of mental illness in the 1970s contributed, in its small way, to greater acceptance of gay people in American culture.

Like Dr. Reiner, I find one aspect of the revision process troubling.  It’s being conducted in secret, and the revisionists are being held by the American Psychiatric Association to confidentiality agreements.  The APA has justified this a couple of grounds: first that it allows the committee to work undistracted by public comment from fellow scientists; and second that it prevents members from accepting outside work, such as casebook writing and other assignments, with an eye toward money.  After all, “The Doctor Who Wrote the Book On Binge Eating” could make a killing on the Oprah Winfrey Show.

While I’m not a scientist, the secrecy does strike me as bad science, and bad policy.  I’d never argue that laypeople, for instance lawyers, should have their comments considered by the APA, but there are many, many psychiatrists, non-psychiatrist MDs, scientists from other disciplines, and psychologists who could provide valuable criticism or validation of the work before it’s plopped onto the public.  While I’m also sure that the drafters are ethical, experts of the highest order, and would never commit misconduct, stranger things have happened.  And there may even be a few laypeople who have thoughts that might be helpful.  Taking homosexuality as an example, there are many people who have non-disabling, non-criminal sexual hangups who might have useful opinions about the fact that “sexual fetishes” are still classified as a form of mental illness.

Make no mistake, the DSM-V will change more than the practice of psychiatry, in ways subtle and profound.  Whether the secrecy with which it’s being drafted will contribute to that change is something we won’t know, until the cat is already out of the bag.

Edit: 12/24/2008 Adam Kolber was kind enough to point out that I had attributed the Neuroethics post to him, when in fact its author is Peter Reiner.  I have edited this post to reflect that.

Filed under: psychiatry