Like many, I’ve been worried that the revision of Diagnostic and Statistical Manual of Mental Disorders, the source for all our diagnoses, could lead to what’s been called the medicalization of normality. But there are even more fundamental problems inherent in the classification system itself. It slots you into a fixed category based on a checklist that ignores many symptoms, and the categories lack any means for measuring the progress of treatment over time.
In my own case, I’ve always had a depression diagnosis (under the DSM-4 system, that’s major depression – recurrent – non-psychotic). I’ve had various symptoms that don’t show up in the official criteria for this category. I’ve discussed some of them – especially anxiety (though it took me many years to think of mentioning it) – with psychiatrists and therapists, and they’ve been quite responsive. The problem is that there were many I never brought up, especially relating to the upside of the cycles that included the recurrent major depressive downside. Those high energy phases didn’t strike me as manic, as I understood the word (no climbing tall buildings or emptying bank accounts), so why talk about feeling incredibly good, or the less friendly but high-intensity fits of rage. What did they have to do with depression?
As John McManamy points out, there’s significant overlap between unipolar recurrent depression with bipolar depression, yet the classification system shuts them into different categories. I don’t know if I’ve been incompletely diagnosed all these years, but I do know that antidepressants have never worked very well for me and that I’ve done much better since I started taking lamictal.
Before the draft came out a couple of weeks ago, I was encouraged by a statement of guiding principles relating to dimensional assessments. The leadership seemed open to changing some of the basic problems of the classification system. You can read their ideas in the FAQ section of the DSM-5 website, especially the description of dimensional assessments. It’s worth quoting:
… In the earlier versions of DSM, as with the current DSM-IV, disorders were described and arranged by category, with a specific list of symptoms for each mental illness. In this categorical system, a person either had a symptom or they didn’t, and having a certain number of symptoms was required to receive a diagnosis. …
… The categorical syndromes do not always fit with the reality of the range of symptoms that individuals experience. … Also, because the criteria for diagnosis are “yes/no” (i.e., does the individual have this disorder or not?), in most cases there is no method in DSM-IV to account for the severity of the disorder, and thus no specified way to determine if the patient is improving with treatment.
… [D]imensional assessments … would allow clinicians to systematically evaluate patients on the full range of symptoms they may be experiencing. For instance, information about depressed mood, anxiety level, sleep quality and substance use would be important for clinicians to know regardless of the client’s diagnosis … [and] would allow clinicians to rate both the presence and the severity of the symptoms … . This rating could also be done to track a patient’s progress on treatment, allowing a way to note improvements even if the symptoms don’t disappear entirely.
This statement and the formation of a Working Group to develop proposals for dimensional assessment led me to hope that the draft might address the rigidity of the classification system itself. It doesn’t do that at all but does add an important element to the categorical approach in the form of severity and frequency ratings. If used in practice, a psychiatrist would have a much more complete picture of all symptoms, not just those that are part of the limited diagnostic definition – as well as new tools for measuring the progress of treatment.
The main practical concern of the draft is the development of very simple questionnaires for clients and psychiatrists to fill out. So there are more checklists, this time with scales to capture severity for the cross cutting dimensions and frequency for the mood disorders. (You can download drafts of the short forms for depression, anxiety and anger as well as the draft dimensional assessment on this page.)
The Dimensional Assessment has questions on the occurrence and severity of symptoms in three “domains” – suicide risk, substance abuse and a cross-cutting group for mood disorders. (This and the other assessment instruments have been developed through a National Institutes of Health program, called PROMIS, that is working on measurement of cross-domain symptoms for the practice of medicine as a whole.)
This dimensional information provides the basis for a severity-scale rating of the total condition of the patient rather than only the diagnosed disorder. The rating can range from normal (not ill at all) to “among the most extremely ill patients.” The questionnaires for specific disorders allow tracking of progress in terms of frequency of occurrence. The depression scale, for example, asks if you felt x in the last seven days, never, rarely, sometimes, often or always. This is hardly a perfect system, but it seems like a step forward in providing a much more useful approach to the condition of a client than that of the static diagnosis.
There are dozens of changes that have provoked severe criticism by many psychiatrists, psychologists, therapists and counselors. One of the most telling – and the one that I can readily confirm from my own attempts to make sense of this complicated document – is inconsistency in the writing and organization of the whole work. Dr. Allen Frances, who chaired the DSM-4 Task Force and is a sharp critic of the current revision, attributes this to lack of coordination and direction of numerous Working Groups that have been focused exclusively on their own subjects with very little communication across groups. The result, he says, is a collection of proposals that are full of ambiguous terms and that lack consistency with one another in terminology and approach. It’s well worth reading his recent critique, Opening Pandora’s Box: The 19 Worst Suggestions for DSM5.
If you haven’t already noticed, discussion and debate about the revisions are all over the media, but a great starting point in the blogging world is John McManamy’s extensive coverage at Knowledge is Necessity. His multi-post report cards on the depression and bipolar revisions are excellent guides, and they comprise only a small part of his detailed and ongoing review. The Carlat Psychiatry Blog also follows the revisions closely.
There will be more to come on DSM-5 here as well. Like it or not, this catechism of diagnosis affects everyone. Next up is an attempt to make sense of the proposed revisions for defining “mental disorder” and for diagnosing major depression.
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Thanks John.
I think diagnosis can be useful to patients if it alleviates their sense of aloneness (‘Oh, it’s not just me).
I think it can be useful to therapists as short-hand. But this is where the problems start: sensitivity to what is outside the templates (expertise is a repertoir of templates). A list of templates necessarily discourages this.
A related issue is quality of life. In the experience of myself and my friends the focus, from GP’s and shrinks, is on treating the ‘illness’ even if this leads to a more limited life for the person.
I think these things can only really be addressed by having a humane kind of training – though changing the diagnostic manual to accommodate more subtlety should be an improvement.
Hi, Evan –
I agree that the templates for each illness tend to restrict thinking. In my experience, good psychiatrists approach therapy with much more flexibility than the diagnostic manual might suggest. In fact, not one has ever mentioned or referred to the DSM during sessions. It seems to have become much more important in this era of 15 minute medication management visits and labeling for purposes of insurance coverage. Humane training is certainly to be hoped for, but today medication is so heavily relied on that sustained therapy (largely for cost reasons) is referred by insurers primarily to counselors with social work or psychology degrees rather than psychiatrists. The therapists don’t make the diagnosis or prescribe the meds in the US.
We’ll have to see how responsive the DSM leadership is to the extensive criticism they’re now getting.
John