Perspectives: DSM-5 and fallacy of biblical analogy

No matter what we choose as our bible, our “clinical canon” – including DSM-5 and CSM-7 – will never match that divine text for us.

June 12, 2013 22:33
4 minute read.
Torah scribe

Torah scribe 521. (photo credit: Courtesy Derech AMI)

At its annual convention in San Francisco last month, the American Psychiatric Association released the fifth version of its Diagnostic and Statistical Manual of Mental Disorders. Already, the tome has acquired two nicknames: “DSM-5” and, like its predecessors, “the bible of psychiatric illness.”

The latter moniker reminds me of a similar phenomenon in my field of oncology. Our publication, The Cancer Staging Manual, now in its seventh edition (CSM-7), is published by the American Joint Committee on Cancer.

We oncologists, also, refer to our official reference guide as a “bible.”

With introduction of the updated DSM, mental health experts have been busily authoring editorials to point out inherent flaws that should preclude referring to the guide as a “bible.”

Dr. Allen Frances, the Duke University professor of psychiatry who chaired the task force of the now obsolete DSM-4, published a list in Psychology Today of the DSM- 5’s 10 most harmful changes. I agree with most of the entries on his list.

For example, in my view as a practicing oncologist, I find that the decision to attach a psychiatric status to all cancer patients does not comport with the reality I observe. Many of my cancer patients quickly find ways to adjust to their illness and to continue to lead meaningful lives.

Also, as with Frances, the medicalization of grief as a “major depressive disorder” troubles me. I fear that, as one consequence of turning grief into a medical illness, doctors may become more inclined to intervene with drugs. And to avoid being considered “diseased,” people experiencing loss of a loved one may be less likely to discuss their feelings with healthcare professionals and to seek consolation from surviving family members and friends.

Similar to activities in the mental-health professions, oncology experts have worked to expose shortcomings within our latest cancer characterization guidelines – shortcomings that presumably prevent CSM-7 from being designated as our “bible.” Critics ask, for example: When we can now use molecular tools to precisely locate and describe tumors, does it make sense to crudely classify breast cancers according to arbitrary linear size, or colon cancers according to how deeply they penetrate the bowel wall? And why don’t we routinely use advanced imaging techniques like MRI and PET scans to determine the extent of diseases like cervical cancer? Unless we at least optimize our diagnostic criteria, the thinking goes, how dare we suggest that we have authored a bible – to be revered at hospitals named Mount Sinai, no less! But my primary concern is not with specific-content critique. My main problem is with the overall premise. I worry about co-opting of the term “bible.”

The word “bible” applies to a text that is not only authoritative but also timeless and immutable. Give or take a bit of quibbling about how to translate Hebrew to Latin, the bibles that rolled off Gutenberg’s press in the 15th century bear the same content as versions ordered today from Amazon.

We purchase scientific books, on the other hand, with the understanding today that content can become outdated almost instantly. Although scientists might seek the comfort of authoritative texts, we know that a scientist is obligated not to tolerate documents that don’t keep pace with progress. So obviously, there must be inherent fallacy in applying the term “bible” to the practical texts of science.

Unless, of course, scientists are using the word “bible” in a broader context.

IN A frequently quoted essay published in a 1994 issue of Tradition magazine, the famous Talmudic luminary Rabbi Chaim Soloveitchik, cautioned about tendency to foster a tyranny of text. Rabbi Soloveitchik implied that the white spaces between the black lines hold more significance than does literal interpretation of biblical verses.

Soloveitchik worried about people quoting the bible literally to impose stringencies on ways in which individuals conduct their lives. In the case of Judaism, the rabbi pointed out that transmission of tradition has, historically, been less literal and more “mimetic.”

I looked up “mimetic” to be sure I had understood Soloveitchik’s message. The word derives from concepts of mimicry and miming. The adjective itself means “imitative” and bears a positive connotation. Soloveitchik, then, urges us not to obsess over literal meaning but to use common sense to identify good people who embody the moral principles of the bible, then to emulate them.

From the laws and parables of our ancient, immutable Bible, we make inferences to guide our continually changing daily lives. A corpus of knowledge also can guide psychiatrists or oncologists, or most other professionals.

No matter what we choose as our bible, our “clinical canon” – including DSM-5 and CSM-7 – will never match that divine text for us, either in authoritativeness or immutability.

However, if by bible we refer to a dynamically updating publication for application in practical settings, then maybe “bible” is a suitable term. Perhaps we can do well to look to our DSMs and CSMs for “divine” guidance.

But as Rabbi Soloveitchik might agree, we ought not lose sight of the white spaces. That way, we can use our bibles –together with our common sense – to do good rather than to impose stringencies to the detriment of other people’s lives.

The writer is a professor of oncology at Tel Aviv University and chairman of the Institute of Radiotherapy at Tel Aviv Medical Center. His organization, Life’s Door, was founded to use serious illness as a springboard for growth and meaning- making.

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