Will the DSM-5 Define Normal?

Or rather, neuro-typical?

I realize phrases like "I'm not normal" and "Who wants to be normal?" and "I never wanted a normal life" are often a person's way of differentiating themselves from what they believe is mainstream (i.e. boring) living. Yet there are many, many people living quiet little wild lives unbeknownst to their neighbor. What looks like the white-bread nuclear family to the casual observer may be anything but. People get altogether too comfortable in their assumptions of how others live and think. Fact is, most of us are actually normal in that we feel a full range of different emotions, can generally trust our senses, have desires, and respond to the trials and tribulations of life with some balance of primal instinct and societal expectation.

Yeah? Well prove it.

Unfortunately, the one diagnostic reference that tells you all of the ways you are abnormal fails to provide guidelines for what is considered within normal limits.

While physical health is somewhat generically considered absence of disease, there are any number of standardized, objective tests that show clinicians where a patient falls within the range of normal. You know if someone's blood sugar has been in control for a few months by drawing a Hemoglobin A1C. You know if someone has a blockage of their coronary artery by performing a cardiac catheterization. You know if someone has a broken arm by getting an x-ray. With mental health disorders, it is subjective report of symptoms coupled with the observation and interaction skills of the clinician that leads to a diagnosis. There is yet no blood test for depression - though we certainly know that low thyroid or Vitamin D levels can contribute. While we can detect brain injury and atrophy, there is no MRI that can yet detect the difference between hallucinations from schizophrenia, bipolar disorder, depression, or substance use. We know certain lifestyle factors correlate with development of mental health problems, from malnutrition, infection, or drug use while in utero to taking too many blows to the head playing football, however thresholds of these biological factors have not been established.

Perhaps if we had a definition of normal mental health, we could identify high-risk individuals and provide primary mental health prevention with education, screening, and management prior to onset or exacerbation of a disorder. Normal grief, normal sadness, normal anger, normal worry, normal happiness - all emotions are appropriate throughout the lifespan, the issues is helping people get in touch with those emotions and be able to evaluate for themselves individual normal limits.

In the meantime, we have yet another tired update to the Diagnostic and Statistical Manual of Mental Disorders, a book developed by the American Psychiatric Association in collaboration with, well, no one except their own psychiatrists, to let the thousands of non-physician mental health providers (you know, the ones that comprise the bulk of the field - social workers, therapists, psychologists, nurses) know how to consistently label people for the purposes of proper billing and coding. Not treatment. Just billing and coding.

It is unsurprising that the National Institute of Mental Health has come out with harsh criticism and calling for more of a biological base to classifications and thereby increase the validity of diagnosis to guide effective treatment. Though they have not formally entered the competitive ring, it is time the  American Psychiatric Association monopoly on mental health definitions fall into line with what is happening in the treatment room. It’s called collaboration. This includes interdisciplinary input from clinicians as well as the lived-experience of the mental health consumer.

Let’s see if the NIMH can do better: http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml

The DSM-5 is scheduled for release on May 27^th – will you get yours?