The revision process for the new version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) has generated fierce controversy in many circles. One of the main complaints raised is the lack of transparency in the process by which new diagnostic concepts are generated. In a recent editorial in Crisis: the Journal of Crisis Intervention and Suicide Prevention, Editor-in-Chief Diego De Leo discussed his own concerns relating to proposed DSM-V changes relating to suicidal behaviour. While self-harm is already included in the DSM-IV-TR as a symptom of various mood and personality disorders, the proposed changes involve creating several new diagnoses including "suicidal ideation and behavior" and "non-suicidal self-injury". A related diagnosis which had been considered for inclusion, "prolonged grief disorder", has been shelved although "bereavement-related disorder" has been proposed in its place.
While the way in which suicide is perceived by mental health professionals has changed extensively over time and across cultures, the current trend towards medicalization of suicide seems virtually complete with the new DSM. In his editorial, Professor De Leo argued that directly assigning a psychiatric diagnosis to suicidal behaviour represents a step backwards from current multi-disciplinary approaches to dealing with suicide. Making suicidal behaviour a DSM-V diagnosis also means shutting out non-mental health professionals who are considered unqualified to make DSM diagnoses which could complicate prevention and treatment. He also points out that slogans such as "Suicide is Everybody's Business" which have been embraced by international suicide prevention organizations would argue against making suicide exclusively a mental health issue.
In countries such as China and India, suicide is far less likely to be linked to psychiatric conditions than in Western countries. In cases of suicide among the elderly, psychological autopsy studies have shown relatively low incidence of psychiatric illness. Although suicidologists Ron Maris and Mort Silverman successfully argued fifteen years ago that "...suicide is, by definition, not a disease, but a death that is caused by a self-inflicted intentional action or behavior", the new DSM-V diagnosis process would automatically make suicide a mental disorder regardless of the actual motivation involved. While any countries have decriminalized suicide, redefining it as a mental disorder would have far-reaching implications into laws regarding the mandatory reporting of suicide attempts and how they are treated by health professionals.
A more profound change being considered in the new DSM is the proposed classification of "non-suicidal self-injury" (NSSI) which would distinguish between deliberate suicide attempts and engaging in self-harm behaviour without intending to commit suicide. Previous versions of the DSM already include non-suicidal self-harm as a sign of Borderline Personality Disorder, which DeLeo's editorial criticises for being too broad a diagnostic label. De Leo also argues that the proposed NSSI category might well be a cure worse than the disease.
There can be many reasons for attempting suicide and differing degrees of suicide intent. Placing "suicidal ideation behaviour" and NSSI into the DSM would limit treatment and diagnosis for suicide attempters by making suicide intention into a "yes/no" dichotomy which often fails to reflect the true extent of the underlying motivation involved. Could the question of whether a self-harm action was intentionally suicidal or non-suicidal even be answered properly? In many cases, the suicide attempter may not even be certain whether the attempt was deliberate or not (as I've observed myself in many cases). In one study described by DeLeo, an Australian community study showed that almost 50 per cent of self-harmers reporting having suicidal ideation, far more than same-age counterparts who did not self-injure, even when the self-harm attempts were not driven by a desire to die. Other studies of self-harmers showed that only a small percentage actually sought medical help for self-harm attempts (self-cutters were even less likely to seek help) despite being at a signficantly higher risk of death than other suicide attempters.
Previous versions of the DSM have shown a tendency to inflate the number of people diagnosed as new diagnostic labels are introduced. The inclusion of suicide attempts as a diagnostic criterion of borderline personality disorder despite limited evidence to support the link led to an increased stigmatization of suicide attempters. Will assigning a diagnosis of NSSI lead to further stigmatization that might prevent suicide attempts and self-harmers from seeking help until it is too late? This is an especially troubling question given the alarming rise in suicide attempts among adolescents (lifetime incidence of self-injury among adolescents can be as high as 14% according to some estimates).
In concluding his editorial, Professor De Leo points out that there is still too much that isn't known about suicide to justify the potential risks involved with the two proposed suicide diagnoses. Since suicide is often a complex process that can be shaped by a range of internal and external factors, including cultural, legal, and economic aspects, directly placing "suicidal ideation and behavior" and "non-suicidal self-injury" in the new DSM may well do more harm than good. In his own concluding words, "As a researcher, a clinician, and a caring human being, I believe we are not ready. Not yet."