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By Alen J. Salerian, MD and Gregory H. Salerian, LICSW
Not to euthanize modern medicine's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) may not be an option in order to help people with imperfect brains for its design is unfit for brain's dynamic and complex function.
DSM-IV has no peer in the international neuropsychiatric world. As the predominant diagnostic instrument to classify neuropsychiatric disorders, DSM-IV's influence dwarfs those of any other entity. The power of DSM-IV is not only felt by billions of sick people but also by the world of research, social policy and countless private and public institutions involved in mental health. This is precisely why DSM-IV's failures make all of us suffer.
The brilliance of brain function - plasticity and complexity - is overlooked by DSM-IV which analyzes the brain as if it is an extension of our skull and bones, and thus it mutilates its brilliance.
To define a disorder based upon hearsay is not a preferred way to make a medical diagnosis and that is why the following evidence seems troublesome.
DSM-IV's language for substance abuse is concise and crisp. For instance, a single condition such as criteria #4 occurring within a 12-month period is definitive. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication).
Hence, someone with a daily consumption of two glasses of wine and whose spouse believes the amount is excessive may be diagnosed as an alcohol abuser (DSM-IV 305.00).
Does the diagnosis require alcohol intoxication, laboratory evidence or blood alcohol measurements? Is cognitive testing necessary to validate the diagnosis? The answer is "no." Without hard data, how can we conclude that the family feud is caused by an underlying medical condition?
Medicine suggests regular use of opiates is a medically necessary and safe practice for a large number of people in need of pain relief. The evidence is equally compelling that the problems associated with opiates almost always correspond to excessive intake or their abrupt discontinuation. It has also been demonstrated that regular intramuscular slow-acting acetylmorphine administration is a safe and effective treatment for some people with narcotic abuse or dependence.
Collectively, all of the above suggests the great majority of the time people can use opiates for long periods safely and without any serious adverse health effects; thus, regular intake of opiates by itself does not constitute abuse or disorder without any evidence of intoxication or withdrawal. And it is because of this scientific observation that one should carefully study the DSM-IV classification of opioid abuse and discover a manmade problem: DSM-IV 305.50 Opioid Abuse Disorder is a phantom disorder.
A section where DSM-IV reveals its prejudice is the diagnosis of Borderline Personality Disorder 301.83.
Any individual with a highly sensitive brain may wrongly be diagnosed with borderline personality disorder. This subtle yet undeniably judgmental label will shadow anyone anywhere as diverse as job, health and life insurance or disability benefit applications. And all of this prejudice because neurobiology mediates our stress response. Many individuals with a psychobiological deficit and with a diagnosis of borderline disorders have heightened responses to stress.
How can anyone with a sensitive brain being diagnosed with borderline personality disorder combat prejudice promoted by DSM-IV?
At different places, the design errors associated with dynamic changes of brain function of DSM-IV are transparent yet never as clear as they are in the sections of attention deficit disorder and cognitive disorder not otherwise specified.
Because of DSM-IV's failure to accommodate brain plasticity, age-associated brain decline can only be diagnosed as Attention Deficit Hyperactivity Disorder not otherwise specified 314.9. An independent category - Cognitive Disorder not otherwise specified 294.9 - is presumed to be due to direct physiological effect of a general medical condition. Hence, in the absence of a medical disorder, the great majority of people with age-associated mild executive dysfunction only meet the category of Attention Deficit Hyperactivity Disorder not otherwise specified. The possible shared biological deficit - prefrontal hypodopaminergic activation - is recognized for adolescents. Billions of aging adults with problems with concentration and memory do not exist according to DSM-IV.
It is true that a proposed new category (mild cognitive dysfunction) was rejected for DSM-IV. It is possible to defend the oversight with hopes of a future inclusion in DSM-V. Yet, this argument cannot address the deficit and signature trait of DSM-IV, the disconnect between the fluidity of brain function and its archaic diagnostic tool.
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