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Editorial
A Warm Welcome to the Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition?
Emran Mohammad Razzaghi MD, MPH●*
The present article discusses the reaction of psychiatric professionals and specifically the academia in Iran to
the publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5). It is
argued that the reaction to changes and the approach of the new revision of DSM has been neither technical, nor
emotional. This argument has further been examined for the previous revisions of the DSM and the conclusion is
that the Iranian psychiatry has become alienated from the need and necessity of classification of mental disorders
from a local and national point of view. The reason for this alienation has further been discussed and has been
focused on the lack of contact between the psychiatric catchment areas and the academia.
Declaration of interest: None.
Citation: Razzaghi EM. A warm welcome to the diagnostic and statistical manual of mental disorders, fifth
edition? Iran J Psychiatry Behav Sci 2014; 8(1): 1-4.
“T he new•••• version of DSM was with a total number of around 1500
released in May 2013 following psychiatrists - 2 per 100,000 population - and
a long process of planning and 9000 psychologists - PhD, MSc, and BSc
research stages that date back to 1999 (1). The holders, altogether - the silence sounds
open challenge however, has not prevented intriguing! I was trained as a psychiatrist
the academia and professionals from under DSM-III, and have witnessed the
expression of their concerns and criticism introduction of the III-R, IV, and IV-TR
regarding the final output of the marathon. versions prior to this recent move. While
The bold opposition of Dr. Thomas Insel, there has been a similar “blunted affect” to
Director of the US National the changes among the Iranian
Institute on Mental Health mental health professionals,
(NIMH) and the response still I recall that in the 1980s
from Dr. David Kupfer, the • The bold opposition of it was not uncommon to hear
Dr. Thomas Insel, Director of the
Chair of APA’s DSM-5 Task judgments about the evolution
US National Institute on Mental
Force has made it clear that of DSM from Iranian key
Health (NIMH) and the response
reactions to an overhaul to the figures such as the late Dr.
from Dr. David Kupfer, the Chair
“Bible” will not be of APA’s DSM-5 Task Force has Haritun Davidian and Dr.
conservative (2,3). made it clear that reactions to an Gholamreza Bahrami, but this
In Iran’s professional overhaul to the “Bible” will not be happened to fade out in the
milieu, however, I have not conservative (2, 3). following years. The
seen any opposition statement prominence of the event for
or response, so far. Although, us, however, is the absolute
dominance of DSM over the ICD in Iranian
psychiatry. In other words, it would not be an
Authors’ affiliation: * Associate Professor, Department of exaggeration to say that the Iranian
Psychiatry, School of Medicine, Tehran University of Medical
psychiatry’s reaction to the distortion of its
Sciences, Tehran, Iran.
• Corresponding author: Emran Mohammad Razzaghi MD, MPH, Bible has been “neutral”. In this article I
Associate Professor, Department of Psychiatry, School of
would like to analyze and discuss the situation
Medicine, Tehran University of Medical Sciences, Tehran, Iran
Tel: +98 9121255458 from a constructive view.
Fax:+98 2155412232
Email: [email protected]
www.ijpbs.mazums.ac.ir Iran J Psychiatry Behav Sci, Volume 8, Number 1, Spring 2014 1
A Warm Welcome to the DSM-V
In recent years there has under discussion. Therefore,
been a substantial rise in the • In other words, it would not be the current more competitive
number of publications in the an exaggeration to say that the academic and training
domain of psychiatry in Iran. Iranian psychiatry’s reaction to the performance may rule out a
Thus, a paucity of publications distortion of its Bible has been direct dwindling of residency
or tendency to question and “neutral” training standards as the
measure events and primary reason for the
phenomena may be out of “bluntness”.
consideration. The inconsistency, however, For us as Iranian professionals the term
might be a sign of basic and methodological “consumerism in science” is a familiar notion.
flaws in the process of science production in Perhaps our understanding of this very term
Iran. In other words, most publications are has been the motive for the current surge in
limited to plain observations, rather than research and publications. However, my
searching for answers to shortcomings and argument here is that our endeavor has not led
unsolved conditions, not mentioning the lack to a level of self-esteem that could lead to
of introduction of hypotheses and the testing of genuine productivity in different scientific
their validity. In search for the precipitating fields nor has it led to accumulation of
and perpetuating factors to this condition, I scientific capital to a level necessary to result
would preferably differentiate the existing in deeper science formation. The Iranian model
situation from the ideal scenario that is under of science consumerism, therefore, may be
examination in this article, by the analogy of defined as an intermediary stage in between
superficial versus deep and profound. Keeping pure duplication and consumption of scientific
in mind my observation that a few decades production of other schools, and actual
back there was deep questioning of the productivity with a particular native
classification of mental disorders, it is by no orientation. We do produce some kind of
means straightforward to think of a knowledge that in its best sense lacks
professional and scientific decline in recent immediate applicability to our current needs
years despite the doubling of the number of and challenges. In search to identify causes of
psychiatrists in the same period. I would rather such aberration I would focus on a specific
try to examine it from the angle of point. We lack an appropriate mechanism to
comprehensiveness of Iranian psychiatrists in translate our questions into research. Replying
the recent past, and would identify it as the to any possible critic that my point, so far, adds
declining element here. Again, would this not much more than what many scholars have
diminishing comprehensiveness be a result of a said repeatedly, by deepening my analysis I
downward slope in psychiatric residency would add however, that we lack the
training? I would rather mechanism to see the question
disagree. Not counting the per se.
individual departments of In return to the DSM issue
psychiatry training initiatives • We do practice psychiatry, but and our bluntness, my
and the hard competition not on a systematized basis; being argument would thus be that
responsive to the mental health not
between universities that have we have not faced questions in
only at individual level but also at
resulted in local reforms in terms of classification of
community level. The current
training programs, the mental disorders, and therefore
psychiatric practice in Iran is on a
curriculum of psychiatric we are neutral to others’
passive basis, and only responsive
residency training was revised positions. The question, here,
to demands and not to needs. As
and extended at national level we do not follow specific and is that while we are practicing
by the Ministry of Health in predefined mental health psychiatry on a daily basis and
late 2000s and a multitude of standards and indicators, there the number of psychiatrists has
training strategies have been are no well-defined infrastructures mounted during the past two
added to previous training responsible for them. decades why are we not facing
approaches in the time-period questions? My answer to this
2 Iran J Psychiatry Behav Sci, Volume 8, Number 1, Spring 2014 www.ijpbs.mazums.ac.ir
Razzaghi OM
important question is not Iran belongs to the private
complicated. We do practice • Classification of diseases in its sector, we need to somehow
psychiatry, but not on a broader sense, and the DSM in “manage” the mental health of
systematized basis; being specific, is a tool for responding to the community. My solution in
responsive to the mental health needs at community level. Fine- this regard is strict adherence
tuning of definitions and criteria
not only at individual level but to “managed care” principles
would affect social standards,
also at community level. The with the departments of
mental health standards, and most
current psychiatric practice in psychiatry in the more
importantly it would make
Iran is on a passive basis, and important universities taking a
adjustments to the financial
only responsive to demands prominent role in this
capital invested in mental health.
and not to needs. As we do not management by taking
follow specific and predefined responsibility of the already
mental health standards and defined - but not well
indicators, there are no well-defined respected and practiced - catchment area of
infrastructures responsible for them. For their university and acting as a protective,
example, almost all school mental health supportive, and advisory umbrella for all the
programs are just a reflection of a mental private and public sector services in fulfilling
health professional eagerness, and not a sign of mental health standards.
demand from the school authorities. Similarly, My earlier point in referring to the
aftercare remains an ideal luxury in our mental expression of “attitude” towards earlier
health service. As a psychiatrist practicing and versions of DSM by late figures in Iran’s
training psychiatry in a most prestigious psychiatry brings me to this interpretation that
academic center in Iran, I have not been taken those figures practiced psychiatry in an era of
responsible for any minimum mental health very limited number of psychiatrists.
standards of a “catchment” community. Nor Therefore, while even in circumstances not
am I involved in pre-hospital and aftercare able to adhere to high standards, they had to
services my patients might be in need of. I remain responsible to minimal demands of the
would argue then, that for this reason, I am not community, just because they were few and
obliged to shift from a consumerist position to were under the pressure of their rarity and
a productive one, and that is the actual reason fame. To them, therefore, changes in DSM or
that my position towards the DSM changes any other classification system would mean
remains neutral. Classification of diseases in higher or lower responsibilities in terms of
its broader sense, and the DSM in specific, is a classifying human behaviors and conditions
tool for responding to needs at community as disorder, aberrant, or normal. Today,
level. Fine-tuning of definitions and criteria however, that the number of mental health
would affect social standards, professionals is more than can
mental health standards, and be identified and taken
most importantly it would • My solution in this regard is responsible by the
make adjustments to the strict adherence to “managed care” community, this would be the
financial capital invested in principles with the departments of responsibility of medical
psychiatry in the more important
mental health. Not to mention universities in general and the
universities taking a prominent role
the primitive approach to departments of psychiatry in
in this management by taking
mental health insurance specific. Having not met this
responsibility of the already defined
industry in Iran; as long as the responsibility, our universities
- but not well respected and
major part of medical have thus engaged in
practiced - catchment area of their
payments is “out of pocket” university and acting as a “fun/luxurious” research, as
and, therefore, not “managed” protective, supportive, and advisory explained earlier. I am afraid I
in any sense, we would remain umbrella for all the private and do not see the likelihood of
indifferent to DSM changes. public sector services in fulfilling any promising alternative that
No matter that the largest mental health standards. could assure reaching the level
fraction of the health system in of having positions towards
www.ijpbs.mazums.ac.ir Iran J Psychiatry Behav Sci, Volume 8, Number 1, Spring 2014 3
A Warm Welcome to the DSM-V
the DSM, in the prospect. http://www.nimh.nih.gov/about/director/2
013/transforming-diagnosis.shtml
References 3. Kupfer D. Chair of DSM-5 task force
discusses future of mental health research
1. American Psychiatric Association. Time
[Online]. [cited 3 May 2013]; Available
line [Online]. [cited 2012]; Available from:
from: URL:
URL:
PrFont34Bin0BinSub0Frac0Def1Margin0M
http://www.dsm5.org/about/Pages/Timelin
argin0Jc1Indent1440Lim0Lim1www.psych.
e.aspx
org/File Library/Advocacy and
2. Insel T. Director's blog: Transforming
Newsroom/Press Releases/2013
diagnosis [Online]. [cited 29 Apr 2013];
Releases/13-33-Statement-from-DSM-
Available from: URL:
Chair-David-Kupfer--MD.pdf
4 Iran J Psychiatry Behav Sci, Volume 8, Number 1, Spring 2014 www.ijpbs.mazums.ac.ir
