Stuck between the phone and the printer is a red book. It's about the size of a cheap paperback novel, but the price tag is still on the cover. $22.49, in 1998 dollars. It's the "DSM-IV," Diagnostic and Statistical Manual, version four, published by the American Psychiatric Association. It's the "quick reference" condensed version
In our front office is the big brother of my little booklet, the unabbreviated version of the book. It's about the size of a box of dog biscuits. I know that because the full-sized DSM-IV sits on a shelf beside the box of biscuits we keep to feed visiting dogs. The DSM-IV we keep to feed the identification numbers of conditions to insurance companies and to feed the collective ego of the American Psychiatric Association's DSM-IV Committee.
Pardon the rant. I went a little overboard there. A little.
These books really do have value. They list in detail every conceivable and some inconceivable mental health conditions that afflict people. The specific clinical value is that there is now enough research into mental health improvement that we know that certain conditions are best addressed by certain interventions for certain people. It helps create standardized clinical pictures of clients. Talk to any colleague about "301.81" and their DSM-IV will tell them it Narcissistic Personality disorders when five or more of the nine listed criteria are met.
Near the front of the book is a "cautionary statement" (read "disclaimer") that reminds the fact that a condition is listed doesn't necessarily mean it has legal or non-medical ramifications and may not be wholly relevant if individual responsibility, disability determination, and competency are issues.
The book suggests "multiaxial assessment" to get the full picture of a client's condition. What is the clinical disorder? Are there personality disorders or mental retardation issues? Are there medical issues? Are there psychosocial or environmental issues? On a scale from 0-100, what is the overall assessment of functioning? ("25" means behavior is somewhat influences by hallucinations. "75" means there are occasional mild symptoms and decent relationships. "100" is livin' the dream; superior function in many areas, no identifiable symptoms of anything. If I ever meet a client in that range, I'll want to ask him/her what she/he is doing in my office. Then I'll as for THEIR help. How DO you do it??!!)
One of my mentors, a psychiatrist and educator of significant repute, calls it "The Big Red Book of Unhappiness" and pretty much shuns it as little more than academically interesting.
The place where the DSM-IV has the most traction is with the segment of the mental health system that follows the medical model. Look at doctors' reports, the blue sheets you take to the lab, or some insurance forms and you'll see a numerical code that refers to the physical condition you have. Once that's known, appropriate tests or proven treatment will begin and if the diagnosis out of the medical model manual is accurate and the treatment is done properly, results are pretty much predictable. Got 272.4, high cholesterol? Watch your diet, take Lipitor or some other statin, and there is a predictable likelihood the problem will be solved or at least lessened.
I'm not so sure that medical model can be simply plopped in the mental health symptom, though. Certainly in mental health, just like physical health, a medication can alleviate a symptom, but with cholesterol, it's quite possible the symptom, too high or two low numbers, is really the condition. Not so with mental health. Depression could be grief and anger could be jealousy. Take an anti-depressant or a mood stabilizer and depression and anger can be better managed, but is the underlying condition fixed? Maybe not. I hasten to add that those medications may be necessary to get a person to a point of "normalcy" where they can begin to address the real issues, but it's a stretch to call them "cures."
The big news, for good or bad, is that the DSM-IV, so venerated for so many years, will soon be relegated to shelf space BEHIND the dog biscuits when the DSM-V is rolled out in a couple years. Previews indicate that there will be very significant changes. The multi-axial assessment, one of the cornerstones of the old book, will be eliminated. Some conditions, including half of the now defined personality disorders, are scheduled to be eliminated. Other newly-defined conditions will be added. Critics say one of the goals is to have virtually everyone classifiable with some kind of official mental health condition. Think of the boon to the economy if you're in the pharmaceuticals business.
But guess what, one of the conditions slated to disappear is 301.81, Narcissistic Personality Disorder, which was mentioned before. It is characterized by the following, and remember, you need to meet five of the nine criteria to get the diagnosis: an exaggerated sense of self importance, preoccupation with fantasies of unlimited power or brilliance, a belief that one is so special, he can only associate with others of similar status, the need for excessive admiration, a sense of entitlement and special treatment, taking advantage of others, unwillingness to recognize the needs of others, being envious or believe others are envious of you, and arrogance. So, while the framers of the DSM-V are exploring ways to include more and more of us in the book, it sounds to me the framers of the DSM-V have exempted their own condition from their own bible!
Again, these ideas can be viewed as a rant, maybe even anxiety or paranoia. (That diagnosis would be 300.02, Axis I; and 301.0, Axis II, for now who knows what else in the DSM-V, due on our bookshelves in 2013.)
It will be a couple years before all this shakes out. In the meantime, Family Services and First United Methodist Church will continue the "So You want to Learn About." series of workshops. Next up, on Monday, Feb. 14, is "What's this counseling stuff all about anyway?" This will be a role-play between two counselors, one acting as a typical client and will demonstrate how people are helped in their efforts to make changes in their lives. The workshop is from 6-7 p.m. in the FUMC parlor and is free to the public.
Gary Lester, M.S., R.T.C. is the executive director of Family Services of Warren County-a charitable agency that provides counseling, substance abuse services, and support groups.