DSM5: Rewriting the Diagnostic Bible

Sometimes a book is more than just a book: it is an occasion for high anxiety.  For instance, in just a few days, the American Psychiatric Association will unveil the fifth edition of its handbook of diagnoses, the Diagnostic and Statistical Manual of Mental Disorders. More than a few – patients and professionals and caregivers – are upset with what they expect to find there. In today’s guest blog, psychiatric nurse practitioner Nina Gaby examines how the controversy might play out in one family:

Nina Gaby

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Appendices become sections. Axes morph. Spectrums of quirk. Structure disintegrates. What is already less science than art becomes even more subjective. The world as she knows it is crumbling. 992 pages. Releases to the big shots on May 18. The final edition isn’t as bad as she thought, reading yet another scholarly review. Maybe she has overstated. Controversy has overshadowed common sense. She takes it personally.

It has done away with the Multi-Axial System. Axes 1-5 initially provided a template on which to place symptoms, psychosocial stressors; quantifying functioning and listing criteria, stuff that people hate to hear, but clinicians rely on. We have only moments to evaluate, diagnose, develop a treatment plan, and find a billable code. You don’t like being reduced to numbers? Okay, says the older sister, then pay for it yourself. Personality still takes on blame, but has lost its own axis. (Is it scrim or lens? the older sister snorts.) The proposed windmills of domain and level and trait, internet process addictions and other tasty problems will reside for the next decade, unreimbursed, in the nether land of Section 3. Others have died altogether.

Bereavement, Excoriation, Hoarding, Asperger’s. No, yes, yes, no.

Bio markers still lack data. The older sister retreats to write her own narrative.

(“Reformulation of Personality Disorders in DSM-5: The work group recommends a major reconceptualization of personality psychopathology…”)

“Your regret must be so far, so much wider than mine,” said one sister to the other. The genogram showed dark bars. Cut-offs. Flattened symbols float across scar tissue.

“We were never like other families,” said the other. She, however, shows no regret. The first sister wants to see the signs of remorse, slash marks across the core. “Show me,” she begs.

“Not happening.”

It’s horrible when you can’t be mad anymore, the first sister thinks.

The first sister doesn’t want the Diagnostic and Statistical Manual to change. Biblical, its criteria like drops of blood. Tribal. She learned its secrets after suicides, after grad school, when she began to see herself as a helper. A map maker clinging with the cliché of an evangelist’s zeal since the Third Edition, which was bright green. Such an odd choice for so serious a text. What color will these girls be now? What if you can’t help?

“I cut you off, summarily, more than death, more than ice crystals.” Dust from the pastel the second sister clutches is bright and azure under her thumbnail. “Ha!” She is proud of color. The other one scribbles in monochrome; she thinks she cannot afford anything else.

A list banners out wide between them, a rip here, a yellow edge crumbles there, the wind tries to play with it. Like a prayer flag.

Holidays come and go. Stones pile up on grave markers. Pizza boxes. Pay stubs. One has many husbands, the other, again, can’t afford that luxury.  She doesn’t want so many lines and bars and slashes on her map. Instead, dots connect here and there, arrows.

“Just wait till 2013. You won’t be able to call me names anymore,” says number two. How does she know that? Her therapist must have told her. Number one plots in the same way she did when they were young. “That’s ugly,” their mother would say.

Come on, really, they ask, who did mom really like best? That was the secret. And it wasn’t that they all had a little too much of this and a little too little of that. “It’s all about gamma-amino butyric-acid deficits,” the smart one smugs. “Or maybe dopamine imbalance.”

“You always try to make me feel stupid,” says number two. “It’s not going to work anymore.” Slash. Cells perform lysis on themselves. Codons break. Pop-it beads drop to the floor. Information scatters in the tailwind of the prayer flags.

No point in lecturing. About dopamine. About responsibility. Family secrets. It’s a transparent defense. Like skin over a genogram, this family map. Time wasted, lines like borrowed eyeliner, like dirty shoelaces, like Christmas ribbons, willow whips, a pattern that explains it all. Only one really cries at the end, sudden and alarming.

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Nina Gaby is a writer, visual artist, and psychiatric nurse practitioner specializing in co-occurring addiction disorders. Gaby has most recently been published in I Wasn’t Always Strong Like This: True Stories of Becoming a Nurse, edited by Lee Gutkind.  She recommends an article in Psychology Today (Susan Krauss Whitbourne, PhD, blog 3-15-13) for an overview on what’s new and old in the DSM-5. She has taught the old DSM since it came out in 1994. She is anxious.