Is the DSM the Bible of Psychiatry?
Is the DSM the Bible of Psychiatry?
Ever since coming to psychiatry from theology a decade ago, I have been repeatedly struck by references in the popular press, and even in some scholarly papers, to the DSM as a "Bible."1 For purposes of this essay, "Bible" refers to a sacred text that—at least in the monotheistic religions of Judaism, Christianity, and Islam—is seen as an authoritative source. The DSM does not refer to a particular version of the manual but rather to the entire process of psychiatric classification that this familiar designation signifies. Finally, the comparison of a scriptural and a diagnostic text is humanistic and does not imply any claims about the scientific or religious truth of either volume. A discussion of the intellectual, social, and historical similarities and differences between sacred texts and the DSM would require a full-length book, but we will concentrate here on 5 main aspects: controversy, communication, interpretation, change, and power.
First, the authority of both books is a matter of controversy and even division. Consider the 2003 Point-Counterpoint in Psychiatric Times on the clinical validity and value of the DSM.2,3 Reflect on almost any recent media debate regarding a divisive political or social issue, such as intelligent design versus evolution, and you will encounter disagreement about the weight and scope of scripture in public discourse.4 Second, both books shape a common language, and hence, categories of thought that facilitate, or at times distort, communication between groups who attribute to the respective texts some measure of authority or at least utility. Whether pastors and believers or clinicians and utilization reviewers, each cadre memorizes codes or verses and quotes criteria or passages in support of, and sometimes in lieu of, empiric evidence and logical argument.
Interpretation of the text is critical to its use or misuse, benefit or harm. The world is currently suffering from the destructive ramifications of religious fundamentalism in almost every tradition. Literal and legalistic readings of any text generally lead to exclusion, judgment, and blind spots. Since the first DSM, critics have raised legitimate concerns regarding a rote or cookbook use of the manual, which loses sight of the individual's story embedded in a biopsychosocial context. Even the DSM itself sounds this cautionary note in its introduction.5
This brand of classificatory fundamentalism is seen all too often among unimaginative or slothful practitioners and managed care reviewers who reduce a multi-determined and complex mood disorder to a handful of digits, basing treatment decisions on the superficial implications of numbers rather than the depth of human pain. Conversely, a wise and judicious clinician or teacher can effectively and reasonably apply the basic categories of the DSM to highlight the differences between panic disorder and schizophrenia, thereby illuminating for student and patient alike something about the possible nature and prognosis of their distress and potential remedies.6 The famous scripture scholar, Walter Brueggemann contrasts these enervating and enlivening forms of interpretation of Scripture, but the words can apply equally to reading of the DSM:
"Nonetheless, we in the church dare affirm that the live word of scripture is the primal antidote to technique, the primal news that fends off trivialization. Thinning to control and trivialize to evade ambiguity are the major goals of our culture. The church in its disputatious anxiety is tempted to join the move to technique, to thin the Bible and make it one-dimensional, deeply to trivialize the Bible by acting as though it is important because it may solve some disruptive social inconvenience. The dispute tends to reduce what is rich and dangerous in the book to knowable technique, and what is urgent and immense to exhaustible trivia."7