Downplaying the DSM, Psychiatry's 'Bible'

[Today’s post is written by Jonathan Holmes, Counseling Pastor at Parkside Church in Cleveland, Ohio. He is also a Council Board member of the Biblical Counseling Coalition. I am grateful for Jonathan’s willingness to provide this important information for our consideration.]

A recent blog post, Downplaying the DSM, informs us that the director of the National Institute of Mental Health (NIMH), Thomas Insel, announced recently that the NIMH will no longer rely on the Diagnostic and Statistical Manual of Mental Disorders (DSM), a longtime guidebook for psychiatry: “While DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been ‘reliablity’—each edition has ensured clinicians use the same terms in the same ways. The weakness is its validity… Patients with mental disorders deserve better.” Undoubtedly, every person currently involved the mental illness/psychiatric disorder conversation---both within the counseling community as well as the larger evangelical church---would agree. Therefore, the current conversation is a very important one.

As part of this discussion, it is both wise and imperative for biblical counselors to be willing to dialogue with those whose critique of our approach sometimes insinuates that biblical counseling is uncaring, ignorant of physiological dynamics, or overly reductionistic. As biblical counselors we want to practice what we counsel; we need to listen well!

The following articles serve as a representation of the wide array of voices within the secular community. Far from being homogenous in their beliefs about mental illness, the secular psychiatric community still remains very much in the process of developing how they think about mental illness and its treatment.

The National Institute of Mental Health Withdraws Support from DSM-V - “In a humiliating blow to the American Psychiatric Association, Thomas R. Insel, M.D., Director of the NIMH, made clear the agency would no longer fund research projects that rely exclusively on DSM criteria. Henceforth, the NIMH, which had thrown its weight and funding behind earlier editions of the manual, would be ‘re-orienting its research away from DSM categories.’ ‘The weakness’ of the manual, he explained in a sharply worded statement, “is its lack of validity.’ ‘Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure’.”

My takeaway: If the NIMH decides to no longer use the DSM-V in their diagnosis because of “its lack of validity” then why are we so often led to believe that there is widespread consensus on the topic of the DSM categories and diagnoses?  For instance in the case of major depressive episodes, the DSM-IV states, “No laboratory findings that are diagnostic of a Major Depressive Episode have been identified.”

Stop Blaming Newton Tragedy on Mental Illness - “There are various problems with Long’s impassioned piece when it comes to “talking” about mental illness, partly due to the fact it contained a slew of questionable diagnoses—Autism spectrum, ADHD, Oppositional Defiant, or Intermittent Explosive Disorder—which aren’t recognized as mental illnesses and better described as learning disabilities or disorders. Police Inspector Michael Brown, who runs the highly respected Mental Health Cop blog, called it “potentially the worst article I have ever read about mental health and violence following an atrocity.” Other critics took issue with the way Long had publically demonized her son as a potential mass murderer. While some complained that Long herself was being demonized as a bad mother, the author from Boise, Idaho, issued a joint statement with one of her erstwhile critics about the need for accessible and affordable mental health care in the U.S.”

My takeaway:  Of course no one wanted to blame mental illness for Adam Lanza’s horrific shooting at Newton. Mental illness was not his issue apparently, but guns were (I’m not a gun control advocate or a gun enthusiast). When is mental illness the cause of certain external problems; when is it okay to blame mental illness?

Our Learned Silence on Mental Health - “We all live in a society where the stigma around mental illness can stop us in our tracks. It’s far more serious than a lack of understanding. People repeat things to you that cut you to the quick and you learn not to tell them what you are going through. Instead, you talk about the Red Sox and gardening.”

My takeaway: A recurring issue that seems to come up with mental illness is the stigma and shame attached with suppressing it. Who in the biblical counseling community would advocate that? While we might disagree on what one’s definition of mental illness is, biblical counselors are always encouraging people to speak and share their thoughts and feelings, to have their personal experience framed by the true wisdom from above.

Is Autism a Form of Mental Illness? - Dr. Steve Grcevich, a local Christian psychiatrist in my area, recently wrote this blog post discussing the fact that autism and other autism spectrum disorders are mental illness: “A mental illness can be defined as a health condition that changes a person’s thinking, feelings, or behavior (or all three) and that causes the person distress and difficulty in functioning. As with many diseases, mental illness is severe in some cases and mild in others. Individuals who have a mental illness don’t necessarily look like they are sick, especially if their illness is mild. Other individuals may show more explicit symptoms such as confusion, agitation, or withdrawal. There are many different mental illnesses, including depression, schizophrenia, attention deficit hyperactivity disorder (ADHD), autism, and obsessive-compulsive disorder.”

He references an earlier article from the NY Times where the author clearly states that autism is most definitely not a mental illness: “Whether reporters were directly attributing Mr. Lanza’s shooting rampage to his autism or merely shoddily lumping together very different conditions, the false and harmful messages were abundant. Let me clear up a few misconceptions. For one thing, Asperger’s and autism are not forms of mental illness; they are neurodevelopmental disorders or disabilities. Autism is a lifelong condition that manifests before the age of 3; most mental illnesses do not appear until the teen or young adult years. Medications rarely work to curb the symptoms of autism, but they can be indispensable in treating mental illness like obsessive-compulsive disorder, schizophrenia and bipolar disorder.”

My takeaway: So, who is right? What is the definition of mental illness we are working with? If we use the National Institute of Mental Health’s definition that it is simply a “health condition that changes a person’s thinking, feelings, or behavior (or all three) and that causes the person distress and difficulty in functioning,” this seems quite broad to me.

When Mental Illness Isn’t - This post discusses the case study of a man diagnosed with bipolar. After doing a series of neurological exams, it turns out the man had autoimmune encephalitis…not a mental illness.

How Stress and Depression Can Shrink the Brain - Here is a study of laboratory tests and empirical, provable data on how stress and depression both may affect the brain. This type of research seems much different to me than how the secular therapeutic community currently thinks through depression and other mental illness, of which there are no medical tests to diagnose, but merely subjective criteria from the DSM.

Addiction Diagnoses May Rise Under Guideline Changes - In what could prove to be one of their most far-reaching decisions, psychiatrists and other specialists who are rewriting the manual that serves as the nation’s arbiter of mental illness have agreed to revise the definition of addiction, which could result in millions more people being diagnosed as addicts, which poses huge consequences for health insurers and taxpayers. While other medical specialties rely on similar diagnostic manuals, none have such influence. “The D.S.M. is distinct from all other diagnostic manuals because it has an enormous, perhaps too large, impact on society and millions of people’s lives,” said Dr. Allen J. Frances, a professor of psychiatry and behavioral sciences at Duke, who oversaw the writing of the current version of the manual and worked on previous editions. “Unlike many other fields, psychiatric illnesses have no clear biological gold standard for diagnosing them. They present in different ways, and illnesses often overlap with each other.”

My takeaway: How is the DSM an “arbiter” of mental illness? If there is no “biological gold standard” then why do we make biology and physiology the only accepted cause of mental illness?

Books that I Have Found Helpful

• The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder (Alan Horwitz and Jerome Wakefield)
• Anatomy of An Epidemic (Robert Whitaker)
• An Unquiet Mind (Kay Redfield Jamison). In her book, which I’ve read several times, the two pillars she returns to most often are her use of lithium and various relationships which have brought her out of her depression and helped her stabilize her mania. Would we not tentatively agree that relationships play a significant role within the context of helping someone with mental illness almost to the same effective level of medication?

[Additional articles by Jonathan Holmes on counseling-related issues may be found at the Biblical Counseling Coalition website.]