A Psychiatry of Tomorrow: DSM-5 and Beyond

When I was an undergraduate studying molecular biology in the early 1990s when the Human Genome Project had just begun, my required coursework included several lectures on the ethical implications of sequencing, understanding, and ultimately being able to manipulate the “code of life.” As members of the generation that might one day be able to purposefully alter individual gene expression, our class was urged to consider the vital questions arising from such potential-How should the new technology be applied? For whom and in what situations? Should it be done at all?

As DSM-5 is being drafted, on the heels of the promise of a “paradigm shift,”¹ I find myself thinking again of such questions, and at the same time wondering why psychiatry as a field, from the top down, does not seem to be widely discussing them. Certainly a debate has been ignited, fueled by the likes of old-guard DSM architects Drs. Robert Spitzer and Allen Frances on the one hand, and current DSM-5 framers forging relentlessly onward to 2013 on the other. But that debate has many facets involving both content and process, and in my mind the most fundamental issues-for example, what constitutes a mental illness and what are the appropriate targets of psychiatric intervention-often seem to be lost in the shuffle.

Towards a Spectral Model of Mental Illness
I have long been fascinated by the “grey areas” of mental illness-those hard to define intermediate zones between normal and pathologic modes of behavior-but have usually found myself siding with those wary of diagnostic expansion. Perhaps that’s an expected stance for a psychiatrist primarily working on an inpatient unit focusing on the treatment of psychosis, where drawing a line in the sand to demarcate pathology is often, though not always, fairly straightforward. On the other hand, I’ve also worked at the other end of the psychotic spectrum, in a “prodromal schizophrenia” research clinic, where debate about the boundaries of mental illness was a daily discussion. As DSM-5 moves towards a more dimensional view of mental illness with the proposal of a “psychosis risk syndrome” and the broadening of other diagnostic categories, the time is ripe for us all to pause and carefully consider the implications of this direction.

The idea of conceptualizing mental illness on a spectrum that spans from normal behavior to clear disorder is not new. Incorporation of a dimensional model was considered for DSM-IV, but eventually abandoned due to “serious limitations,”² including the belief that categorical boundaries are vital to clinical decision making. In order to define those boundaries more reliably, DSM-IV was the first edition of the manual to fully integrate a requirement of “clinically significant distress or impairment of functioning” into the criteria for each disorder (though the “not otherwise specified (NOS)” disorders lack both symptomatic criteria and any explicit requirement of distress/impairment). In contrast, recognizing that few patients neatly fit DSM-IV disorder criteria and that NOS diagnoses abound, a central agenda for DSM-5 has been to move towards a dimensional view of mental disorder.³

There are reasonable arguments on either side of the debate over such dimensionalization. On the one hand, those wary of adopting a spectral view of mental disorder are concerned that psychiatry is already guilty of over-diagnosis, with the number of cataloged mental disorders more than tripling from DSM-I (106 disorders) to DSM-IV (357 disorders) and the most recent epidemiologic studies indicating that about half of Americans will meet criteria for a DSM-IV disorder at some point in their lives.⁴ With dimensionalization, this diagnostic boundary will almost surely be expanded further, suggesting that if it’s not already the case, it will soon be “normal” to have a mental illness. Such alarming and seemingly oxymoronic conclusions threaten the already shaky reputation of psychiatry in the public eye, where many are already worried that “psychiatrists think everyone is crazy.” Professional skepticism about diagnostic expansion is just as abundant, particularly with specific DSM disorders such as major depression,⁵ bipolar disorder,⁶ post-traumatic stress disorder (PTSD),⁷ social phobia,⁸ attention deficit hyperactivity disorder (ADHD),⁹ and autism.¹⁰ At their core, each of these arguments contends that psychiatry is overstepping its bounds by applying a label of pathology to some variant of normal human existence and behavior.

On the other side of this debate, defenders of diagnostic expansion argue that available research findings do support identification of and intervention at the “soft” end of spectral conditions such as bipolar disorder, depression, and psychosis. At a phenomenologic level, the dimensionalization position is intuitively defensible given that many of the core symptoms that make up DSM criteria-anxiety, dysphoria, and even psychosis-are indeed part of normal everyday human existence. Admittedly, for me this is one of the things that makes psychiatry so interesting-the very real sense that mental illness is, to paraphrase Susanna Kaysen,¹¹ “you or me…amplified.”

A Psychiatry of Tomorrow
Ever since DSM-III, the hope has been that neurobiological research of categorical diagnoses would result in the discovery of underlying pathophysiologies that would in turn elevate DSM disorders to the status of “disease entities.” Thirty years later, that vision remains unrealized. For DSM-5 and beyond, the new hope is that a spectral view of mental illness that addresses the continuum between mental disorder and mental health will better facilitate etiologic research resulting in the discovery of underlying mechanisms of symptoms as opposed to disorders per se (e.g. it is more likely that mechanisms for “fear” or “paranoia” will be discovered than for “PTSD” or “schizophrenia”). Perhaps when future revisions are truly informed by research into spectral models of mental illness, a DSM reflecting a true “paradigm shift” will bear little resemblance to DSM-IV or DSM-5 and will instead take the form of something more akin to the Research Domain Criteria (RDoC) currently in development at the National Institutes of Mental Health.¹²

If the promise of that vision is realized, the end-game in psychiatric research will include not only the elucidation of “pathologic” processes, but “normal” neuropsychologic processes as well-just as the early study of simple genetic mutations paved the way for the full sequencing of the DNA code in the Human Genome Project. Therefore, while the hope has been that the discovery of underlying pathophysiologies would result in the validation of psychiatric disorders, it becomes apparent that discovering an underlying biological mechanism to account for a mental process or behavior does not alone make it pathological. Thresholds of “pathology” or “disorder” will always require some value-based judgment about “clinical significance”¹³ or “harmful dysfunction.”¹⁴ On the other hand, what elucidated genetic or biochemical mechanisms do reveal is the potential to intervene using biologically-based strategies.

While I have spent considerable time pondering what is and is not a mental disorder, and wondering whether it “should” be the role of psychiatrists to intervene at the soft end of disorder spectrum,¹⁵ it appears that such debate is becoming increasingly academic rather than clinically pertinent. Clinical intervention is not and will not be dictated by DSM definitions of mental disorder, but by the discovery and availability of interventions. Intervention already occurs across a spectrum of suffering, from traditional medical diseases (e.g. cancer) by medical doctors to “problems of everyday life” by clergy and all points in between. What will change as the doors of dimensionalization open into the psychiatry of tomorrow is the potential, through pharmacologic and other “somatic” interventions, to change the course of both pathologic as well as normal mental processes and behaviors. Such potential to make people “better than well” through “cosmetic psychopharmacology” was widely discussed at the beginning of the selective serotonin reuptake inhibitor (SRRI) era with the publication of Listening to Prozac,¹⁶ but has since been strangely absent in mainstream American psychiatry.

Neuroethics
Perhaps clinicians and patients feel comfortable relegating questions about whether this is where psychiatry “should” be headed to the domain of ethics. Indeed, some have now proposed the creation of a specific branch of “neuroethics” where debates about “neuroenhancement” are already ongoing.^17,18 But these issues are not merely ethical or philosophical, as if a part of some imagined, futuristic Brave New World or Gattaca. As scientific discovery and DSM embrace a spectral view of brain disorder and inch more closely to unraveling the biological basis of not only “disease states,” but normal mental processes and behaviors as well, these questions will become more timely and pertinent before we know it. As such, it is already time for DSM architects, clinicians, researchers, patients, and families to seriously ponder them.

Although such discussions have begun to emerge concerning the development of the “cognitive enhancers,”^19,20 the questions that arise-Who should get them? Would taking them confer an “unfair advantage” upon those with access to them? Would you still be the same person if you took them? How would their widespread use transform our notions of “normal” vs. “ideal” functioning? Could some individuals be mandated to take them? Should they be regulated? Should psychiatric physicians be involved in the practice of enhancement? Should insurance companies reimburse for such therapies?-apply to any future interventions for the softer end of the mental illness spectrum.

Elsewhere, I cautioned that:
“The intrusion of diagnostic labels onto traits and behaviors previously considered normal threatens the legitimacy of psychiatry as a medical field. At its worst, it paves a path from well-intentioned cosmetic psychopharmacology to the perils of eugenics.”²¹

Accordingly, and echoing concerns about “unintended consequences” voiced by Dr. Frances,^22,23 it is now important to cautiously consider how the inclusion of spectral views of mental disorder in DSM-5 could contribute to inappropriate medicalization of “problems of daily living” and the sanctioning of pharmacologic interventions for conditions where evidence-based practice does not yet exist (e.g. indiscriminate use of antipsychotics for the “psychosis risk syndrome”). While no skeptic of diagnostic expansion is arguing that we shouldn’t intervene for all forms of suffering, both mild and severe, a careful analysis about how best to intervene based upon controlled research is absolutely necessary. Likewise, at some point, psychiatrists will have to decide whether our field should expand to include neuroenhancement towards an ideal of “perfect” functioning or whether our goal is to help people cope with the normal, inherent suffering of everyday life and the natural limitations of the human body. Anyone is entitled to the right to the “pursuit of happiness,” but it is worth considering whether that “pursuit” is best conceptualized as a Sisyphean process distinct from attainment or satisfaction.²⁴

At the same time, I believe that for many domains of psychopathology, a spectral view does reflect biological reality and that etiologic discoveries do require a shift to dimensional models of mental illness. However, DSM-V doesn’t need to exist for a dimensional approach to research to take place-such inquiry has already been ongoing for years. In fact, I would argue that DSM revisions should follow this kind of research rather than the other way around. Yet it seems that the move towards dimensionalization in DSM-V has already begun and that an immediate impact on clinical practice is inevitable. It is within arenas in which categorical judgments about mental pathology are both essential and have significant and potentially harmful consequences-the aspects of clinical intervention described above as well as with the various “third parties” that use DSM (e.g. governments deciding resource allocation, insurance companies reimbursing for care, the legal system making decisions about moral responsibility)-that thoughtful decisions must be made about how best to adapt to a spectral view of mental illness. It is therefore our collective destiny that ethical discussions about what could occur will soon become practical discussions about what does occur.

References1. Kupfer DJ, First MB, Regier DA. A Research Agenda for DSM-5. American Psychiatric Association, Washington DC, 2002.
2. The American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. American Psychiatric Association, Washington DC, 1994.
3. Regier DA, Narrow WE, Kuhl EA, Kupfer DJ. The conceptual development of DSM-5. Am J Psychiatry. 2009;166:645-650.
4. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey replication. Arch Gen Psychiatry. 2005;62:593-602.
5. Horwitz AV, Wakefield JC. The loss of sadness: How psychiatry transformed normal sorrow into depressive disorder. Oxford: Oxford University Press; 2007.
6. Patten SB, Paris J. The bipolar spectrum-A bridge too far? Can J Psychiatry. 2008;53:762-768.
7. Spitzer RL, First MB, Wakefield JC. Saving PTSD from itself in DSM-5. J Anxiety Disorders 2007;21:233-241.
8. Lane C. Shyness: How normal behavior became a sickness. New Haven: Yale University Press; 2007.
9. Sciutto MJ, Eisenberg M. Evaluating the evidence for and against for the overdiagnosis of ADHD. J Attention Disorders. 2007;11:106-113.
10. King M, Bearman P. Diagnostic change and the increased prevalence of autism. Int J Epidemiol. 2009;38:1224-1234.
11. Kaysen S. Girl, Interrupted. New York: Turtle Bay Books; 1993.
12. http://www.nimh.nih.gov/research-funding/rdoc.shtml. Last accessed June 1, 2010.
13. Spitzer RL, Wakefield JC. DSM-IV diagnostic criterion for clinical significance: Does it help solve the false positive problem? Am J Psychiatry. 1999;156:1856-1864.
14. Wakefield JC. Diagnosing DSM-IV-Part 1: DSM-IV and the concept of disorder. Behav Res Ther. 1997;633-649.
15. Pierre JM. Challenging the “dis-ease” model. Psychiatric Times. August 26, 2009. http://www.psychiatrictimes.com/display/article/10168/1444765. Accessed June 1, 2010.
16. Kramer PD. Listening to Prozac. New York: Viking; 1993.
17. Farah MJ. Neuroethics: The practical and the philosophical. Trends in Cog Sci. 2005;9:34-40.
18. Cheung E. A new ethics of psychiatry: Neuroethics, neuroscience, and technology. J Psychiatric Practice 2009;15:391-401.
19. Farah MJ, Illes J, Cook-Deegan R, et al. Neurocognitive enhancement: what can we do and what should we do? Nature Rev. 2004;5:421-425.
20. Greely H, Sahakian B, Harris J, et al. Towards responsible use of cognitive-enhancing drugs by the healthy. Nature. 2008;456:702-705.
21. Pierre JM. Deconstructing schizophrenia for DSM-5: Challenges for clinical and research agendas. Clinical Schizophrenia and Related Psychoses. 2008;2:166-174.
22. Frances A. A warning sign on the road to DSM-V: Beware of unintended consequences. http://www.psychiatrictimes.com/display/article/10168/1425378. Last Accessed June 1, 2010.
23. Frances A. Opening Pandora’s box: The 19 worst suggestions for DSM5. http://www.psychiatrictimes.com/dsm-v/content/article/10168/1522341. Last Accessed June 1, 2010.
24. McMahon DM. Happiness: A history. New York: Atlantic Monthly Press; 2006.