Is the DSM the Bible of Psychiatry?

Ever since coming to psychiatry from theology a decade ago, I have been repeatedly struck by references in the popular press, and even in some scholarly papers, to the DSM as a "Bible."¹ For purposes of this essay, "Bible" refers to a sacred text that-at least in the monotheistic religions of Judaism, Christianity, and Islam-is seen as an authoritative source. The DSM does not refer to a particular version of the manual but rather to the entire process of psychiatric classification that this familiar designation signifies. Finally, the comparison of a scriptural and a diagnostic text is humanistic and does not imply any claims about the scientific or religious truth of either volume. A discussion of the intellectual, social, and historical similarities and differences between sacred texts and the DSM would require a full-length book, but we will concentrate here on 5 main aspects: controversy, communication, interpretation, change, and power.

First, the authority of both books is a matter of controversy and even division. Consider the 2003 Point-Counterpoint in Psychiatric Times on the clinical validity and value of the DSM.^2,3 Reflect on almost any recent media debate regarding a divisive political or social issue, such as intelligent design versus evolution, and you will encounter disagreement about the weight and scope of scripture in public discourse.⁴ Second, both books shape a common language, and hence, categories of thought that facilitate, or at times distort, communication between groups who attribute to the respective texts some measure of authority or at least utility. Whether pastors and believers or clinicians and utilization reviewers, each cadre memorizes codes or verses and quotes criteria or passages in support of, and sometimes in lieu of, empiric evidence and logical argument.

Interpretation
Interpretation of the text is critical to its use or misuse, benefit or harm. The world is currently suffering from the destructive ramifications of religious fundamentalism in almost every tradition. Literal and legalistic readings of any text generally lead to exclusion, judgment, and blind spots. Since the first DSM, critics have raised legitimate concerns regarding a rote or cookbook use of the manual, which loses sight of the individual's story embedded in a biopsychosocial context. Even the DSM itself sounds this cautionary note in its introduction.⁵

This brand of classificatory fundamentalism is seen all too often among unimaginative or slothful practitioners and managed care reviewers who reduce a multi-determined and complex mood disorder to a handful of digits, basing treatment decisions on the superficial implications of numbers rather than the depth of human pain. Conversely, a wise and judicious clinician or teacher can effectively and reasonably apply the basic categories of the DSM to highlight the differences between panic disorder and schizophrenia, thereby illuminating for student and patient alike something about the possible nature and prognosis of their distress and potential remedies.⁶ The famous scripture scholar, Walter Brueggemann contrasts these enervating and enlivening forms of interpretation of Scripture, but the words can apply equally to reading of the DSM:

"Nonetheless, we in the church dare affirm that the live word of scripture is the primal antidote to technique, the primal news that fends off trivialization. Thinning to control and trivialize to evade ambiguity are the major goals of our culture. The church in its disputatious anxiety is tempted to join the move to technique, to thin the Bible and make it one-dimensional, deeply to trivialize the Bible by acting as though it is important because it may solve some disruptive social inconvenience. The dispute tends to reduce what is rich and dangerous in the book to knowable technique, and what is urgent and immense to exhaustible trivia."⁷

Change
The more conservative view of sacred texts is that they are unchanging, and yet we all are familiar with different versions of the Bible: translations in accordance with new linguistic, archaeologic, and historical discoveries. Similarly, each revision of the DSM is in response to progress in epidemiology, genetics, and neuropsychiatry. Nor are groups of scholars who convene to approve a new translation of ancient texts all that different in purpose or prominence in their fields from the DSM work groups that hammer out a consensus on disorders.⁵ Gadflies of many persuasions would argue that politics and society influence these revisions at least as strongly as scholarship.

The use of gender-neutral language in scriptures and the removal of homosexuality as a disorder from the DSM are both cultural expressions, albeit positive ones, of social change.^5,8 Both the DSM and sacred texts have been necessary but not sufficient guides for those religious or scientific followers who attempt to practice according to their principles. Visit any library in the country and you will find shelves of scriptural commentaries, dictionaries, and journals devoted to the study of sacred texts. While the trees sacrificed to the discussion of the DSM cannot equal those for biblical exegesis, there are nonetheless casebooks, videos, and thousands of research articles dedicated to the explication of the statistical manual.

Power
The last aspect of overlap between scripture and the DSM I will examine is also the most important: the power of each text to affect the lives and self-understandings of human beings. Both the sacred texts and the DSM are able to reify concepts: to define what thoughts, experiences, and behaviors are normal or pathologic, sinful or saintly. In Crowe's phrase they can "construct normality."⁹ I often caution my residents to refer to patients as persons with a disorder not individuals who are a disorder. Likewise, I try to remind my religious studies students that at least in an academic institution, sacred texts are avenues of openness, not one-way streets of condemnation.

Yet stigma research shows that to be labeled as an "anorexic" or a "schizophrenic" may not be all that far from being branded a sinner or damned in terms of its detrimental effect on self-image and future possibilities.¹⁰ Orthodoxy and mental health may in their seemingly separate purviews be the keys to acceptance and community support, even to employment and insurance. In an ideal world, the DSM code for bipolar disorder would unlock the door to state-of-the-art pharmaceutical and psychosocial treatments, as well as a measure of self-acceptance and family healing. In a parallel universe, sacred texts would foster the justice and peace they all universally teach instead of being taken in vain as the instigator of wars and oppression of the poor.

New knowledge from whatever domain-sociologic, scientific, or historical-epidemiologic-represents a challenge to the received wisdom of either the DSM or the sacred text. A foundational assumption of at least the 3 Western religions is that each of their scriptures represents the culmination and completion of revelation. Yet they must arrive at a religious response congruent with their tradition to unprecedented ethical and social developments, such as in vitro fertilization, nuclear war, and multinational corporations. While change appears intrinsic to the entire history of the DSM from I to IV-TR, and now with V in the preparatory stages, a wholesale embrace of dynamism may abdicate any pretense to empiric reliability, leaving one with only heuristic meaning. Hence the calls of many thoughtful psychiatrists to either supplant or supplement the rigid categorical structure of the DSM with a more dynamic dimensional approach precisely because it would have the flexibility to embrace the latest findings of genomics and neuroimaging without losing its integrity.¹¹

Millennia ago both Jews and Christians faced an analogous conflict in determining which of many circulating texts were definitive. Religious experts had to discriminate between those books that were expressions of the spiritual experience of their faith and founders and those that were to be set aside from the sacred.⁵ How different is this process from our current efforts to push the established boundaries between bipolar disorder and schizophrenia as once decades ago we rejected the distinction between neurosis and psychosis?¹²

Should these brief comparisons be unconvincing, I would ask the reader to apply the following passage from the Encyclopedia of Bioethics on the religious authority of Scripture to the DSM as he or she knows it and decide for himself whether the DSM is indeed a kind of Bible.

"One way or another, the authority of a specific text is established. . . . But how is what the text really says determined, and who gets to make those determinations? There are the fundamental issues about religious authority in monotheistic religions. Deeming the text authoritative does not solve the problem of which persons or institutions should determine the text's meaning or the text's solution to various unforeseen circumstances that inevitably arise."¹³

Dedicated to Ronald Pies, MD, encephiatricist, in gratitude for his inspiration. Dr Geppert is chief of behavioral care consultation and medical director of the substance abuse residential rehabilitation treatment program at the New Mexico Veterans Affairs Health Care System in Albuquerque. She is also assistant professor in the department of psychiatry and associate director of religious studies at the University of New Mexico in Albuquerque. This column was formerly titled "Starting Out," and it focused on issues of the psychiatrist newly in practice. Now that Dr Geppert is moving out of the early career phase, her new column, "Windows," will take a wider view of the world of ethics and meaning in psychiatry.

References:

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2. Genova P. Dump the DSM! Psychiatric Times. 2003;20(4):72, 75.
3. First M, Spitzer RL. The DSM: not perfect but better than the alternative. Psychiatric Times. 2003;20(4):73, 77-78.
4. Peters T, Hewlett M. Evolution From Creation to New Creation. Nashville, Tenn: Abingdon; 2003.
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Text Revision. 4th ed. Washington, DC: American Psychiatric Association; 2000.
6. Boyce P. Restoring wisdom to the practice of psychiatry. Australas Psychiatry. 2006;14(1):3-7.
7. Brueggemann W. Biblical authority. The Christian Century. Jan 3-20, 2001:14-20.
8. Spitzer RL. The diagnostic status of homosexuality in DSM-III: a reformulation of the issues. Am J Psychiatry. 1981;138:210-215.
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12. Moller HJ. Bipolar disorder and schizophrenia: distinct illnesses or a continuum? J Clin Psychiatry. 2003;ˆ64(suppl 6):23-28.
13. Gross RM. Authority in religious traditions. In: Post SJ, ed. Encyclopedia of Bioethics. Vol 1. 3rd ed. New York: Macmillan; 2004:235-242.