Why Are People So Interested in the DSM-5?

Scientific American

There is a lot of internet buzz about the approval by the American Psychiatric Association's (APA) board of trustees of its fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5.)

The APA press release notes "the trustees' action marks the end of the manual's comprehensive revision process, which has spanned over a decade and included contributions from more than 1,500 experts in psychiatry, psychology, social work, psychiatric nursing, pediatrics, neurology, and other related fields from 39 countries."

The approval was announced on Saturday, December 1 (was the APA trying to keep it quiet?) with publication of the DSM-5 scheduled spring 2013. For a book that has no plot or characters, its pending publication has caused great excitement. True, it is a sequel, but it is not the latest installment of Harry Potter or the Twilight Saga.

Though the DSMs have not reached the volume of sales of a Harry Potter (so far), the paperback edition of the last version of the DSM had a sales rank of 261 on Amazon.com. This is remarkable for a book that is over 900 pages in length and written for professionals.

Besides being bestsellers, the DSMs have inspired games and even music awards. DSM-IV the Game is available for free online. It is described as "beautiful way to engage and learn about yourself, family, and friends and as an ice breaker at your next holiday gathering."

Several years ago, Dr. Jill Squyres, a clinical psychologist in San Antonio, created the DSM-IV Music Awards for her professional society's fall social. The DSM-IV Music Awards are modeled on the Academy Awards. She chooses categories based on a DSM diagnosis and then nominates songs that are reflective of disorders such as Major Depression (Jagged Little Pill by Alanis Morisette, King of Pain by the Police), Mania (Wake Me Up Before You Go Go by Wham, Life in the Fast Lane by the Eagles), Obsessive-Compulsive Disorder (I'm In Love With My Car by Queen, Pinball Wizard by the Who), and Borderline Personality Disorder (Isn't life Strange by Jim Morrison, Addicted to Love by Robert Palmer).

How does a medical book about psychiatric disorders inspire games and awards let alone become a bestseller? There are not enough medical professionals or people with vested interests, such as the pharmaceutical or insurance industries, to account for these sales figures. What is behind the fascination with the DSM among the general public? I believe it is because our mental state goes to the core of who we are as human beings and our fascination with the link between mental illness and creativity.

Mental illness went "public" long before cancer and AIDS. Although mental illness is still considered a stigma by the general public, writers and artists have been talking publicly about their bouts of depression and struggles with alcohol and drugs for hundreds of years. Ernest Hemingway, Virginia Woolf, Sylvia Path and Vincent van Gogh committed suicide. The poets T.S. Eliot and Ezra Pound were committed to mental institutions. The 27 club is comprised of musicians who died at age 27; Janis Joplin, Jimi Hendrix, Brian Jones, Kurt Cobain, and Amy Winehouse. The public breakdowns and rants of Mel Gibson, Alec Baldwin, Lindsay Lohan, Charlie Sheen and Mel Gibson have been televised and viewed by millions on YouTube.

The style and language of the DSM is another reason for its popularity. Unlike most medical textbooks , there is relatively little medical terminology and diagnoses are described in terms that are easily understandable to the nonmedical reader. Each diagnosis includes a list of symptoms, referred to as criteria, that typify the disorder. The list of symptoms is exhaustive, but not all symptoms necessarily occur in the disorder. The format and clear non-technical language invite the reader to examine and apply this new knowledge to themselves and others. A parent who worries that his child might have Attention Deficit Hyperactivity Disorder (ADHD) or a spouse concerned that their loved one is displaying symptoms of Alzheimer's disease can easily look up these disorders and review the symptom check list.

Psychiatric disorders consist of behaviors that are extreme. The same behaviors occur with less intensity or frequency in everyday living. A key symptom of Major Depression Disorder is anhedonia, a failure to find pleasure in everyday life. Anhedonia was the working title of Woody Allen's movie Annie Hall, which won four Academy Awards including Best Picture. In mild or moderate degrees, most of us have experienced "mild anhedonia" (a.k.a being in a funk) at some point in our lives.

Obsessive-compulsive disorder (OCD) is an anxiety disorder marked by obsessions, which consist of unwanted and repeated thoughts, or behaviors, and compulsions that make those with OCD feel compelled to perform a behavior to lessen their anxiety. Although most of us are not paralyzed by OCD, we all have some traits. We go back and check to see if we locked our doors or left the tea kettle on. And although we might wish to have the detective skills of Adrian Monk or the writing skills of Jack Nicholson in As Good As It Gets , these fictional characters inability to cope with OCD causes them great anguish and the inability to have significant relationships.

I believe that today's films and TV shows that portray mental illness are popular because they present characters we can relate to, unlike earlier films such as Psycho, a film that scared people so much they stopped taking showers. We laugh at the neurotic mother-son relationships portrayed in Everyone Loves Raymond and Seinfeld because we can relate to them. And we worry about our children. Are we pushing them so hard that they will end up like Natalie Portman's crazed ballerina in the Black Swan?

Brain scans have shown that that creativity and "madness" light up similar pathways in the brain. However, the overwhelming majority of mentally ill people are not artists and most artists are not mentally ill. Edgar Allen Poe, Vincent Van Gogh and Ernest Hemingway were gifted artists who happened to be mentally ill. Their mental illness did not make them artists. In fact, mental illness interferes with the artistic process. William Styron was not able to write in the throes of his depression. The mathematician John Nash did his greatest work before he was diagnosed with schizophrenia.

I have no doubt that some gifted people are able to function by "throwing themselves into their art." However, their legacy is their work, not their mental illness. People may fantasize about being able to play guitar like Jimi Hendrix, write like Hemingway, and sing and dance like Michael Jackson. But they don't fantasize about being clinically depressed, overdosing on drugs, being homeless, or being institutionalized.

To answer to my question of why we are so fascinated by the DSM, I believe it is because it presents and explains extremes of behavior, related to and connected with the more normal levels of behavior we experience. We read the DSM to find ourselves in its pages.

Images: Vincent Van Gogh; Janis Joplin; MONK cover by author.

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