The publication of the fifth version of the Diagnostic and Statistical Manual of Mental Disorders – usually referred to simply as ‘the DSM’ – is due round about the time you receive this edition of Underwriter e-Alert. (We’re naturally pleased but it may be only coincidence at work.) This mighty reference work from the American Psychiatric Association is not just the ‘bible’ by which psychiatric conditions are classified and diagnosed; the DSM is used the world over by researchers, drug regulation agencies, pharmaceutical companies, and policy makers – and by insurance companies, especially health insurers.
Compared with DSM-IV, edition V promises to be bigger and better, with improved diagnostic information and the inclusion of many new psychiatric conditions. While one body of opinion says the expanded DSM-V is helpful in increasing understanding of mental disorders, leading to better clinical management and thus benefiting patients, others say that it has gone too far, ‘medicalising’ variations of normal human behaviour. This latter group cites the inclusion of conditions like skin-picking disorder, hoarding disorder (previously a form of obsessive compulsive disorder but now standing alone) and female orgasmic disorder (look it up). The diagnostic criteria for binge eating disorder might make you wonder about consulting your analyst about something new. Hypersexual disorder and Internet addiction disorder also feature, but only in section III covering areas for future research.
This trend towards medicalization is nothing new, and it stems from our rapidly increasing understanding of things medical – well of almost everything actually. There is nothing much wrong in labelling things, but there may be something wrong in thinking that every one of them is deserving of treatment. You could be forgiven for thinking the DSM-V sounds like a significant business opportunity for psychiatrists.
We humans are all different, and those differences help make life potentially such a rich and rewarding experience. If someone’s behaviour or their mood or a facet of their personality means they have difficulty functioning, they may well need some help, be that medication, cognitive behavioural therapy, counselling or whatever. One hopes that clinicians will remember that.
Equally, as underwriters we need to remember that just because something has a label, it does not necessarily constitute an extra risk, especially for mortality. Evaluating psychiatric risks has never been easy. We hope that it is not to become even less so.