The brand new book of human troubles

With three years still left until publication, the fights over the new version of the psychiatric diagnostic manual, the DSM-V, are hotting up and The New York Times has a concise article that covers most of the main point of contention.

“What you have in the end,” Mr. Shorter said, “is this process of sorting the deck of symptoms into syndromes, and the outcome all depends on how the cards fall.”

Psychiatrists involved in preparing the new manual contend that it is too early to say for sure which cards will be added and which dropped.

Although I doubt the DSM committee are using that exact metaphor, it certainly illustrates the point that the process requires a certain degree of value-judgement.

It’s interesting, however, that the public debate is currently focused on whether certain diagnoses should be included or not, rather than whether diagnosis itself is useful for psychiatry.

We’ve had psychometrics for a good 100 years that allow us to measure dimensions of human experience and performance with a much greater degree of accuracy than clinical diagnosis allows.

The slightly obsessive need to classify everything is both an inheritance from the infection model of disease, where one either has the pathogen or does not, and is encouraged by the US health care system, where insurance companies will only pay for treatment if it is diagnosed with an ‘official’ diagnosis.

Nevertheless, it is perfectly possible to treat someone based on continuous measures of distress, impairment and functioning using evidence-based cut-off points to judge whether a particular treatment should be applied.

In fact, many physical diseases are treated in exactly this way. The definitions of obesity, hypertension, diabetes and many others rely on an evidence-based cut-off point on a continuous scale of weight, blood pressure and blood glucose level.

There is no qualitatively different cut-and-dry distinction between just below the cut-off and just above it – it’s just the point at which outcome studies predict that other things get much worse.

So rather than questioning the process, we need also to question the system, because diagnoses are tools and we need to know when and where they are most useful.

Link to NYT ‘Psychiatrists Revise the Book of Human Troubles’.

2 thoughts on “The brand new book of human troubles”

  1. This is a pretty complex topic, obviously, and I will admit to not being very familiar with much of the psychometrics literature. And I am certainly biased having trained as a psychiatrist, but I would like to add a few thoughts in support of diagnosis.
    I would agree that the categories and specific diagnoses are to a significant degree arbitrary when it comes down to the nitty gritty of evaluating an individual patient. Nonetheless, I think that focusing only, or even primarily, on symptoms is a mistake.
    An individual symptom, such as hallucination or delusion, can appear in various constellations of symptoms (which we circumscribe and treat as diagnostic entities). The treatment approach to someone with e.g. a delusion varies (and should, according to the evidence) depending on what other symptoms also appear. In other words, if your delusion is a feature of OCD or PTSD, I will understand and approach the symptom differently than if it is part of schizophrenia or dementia.
    The medical model certainly has limitations, but I do believe it is useful. By the way, I don’t think this model is based on primarily infectious disease, nor is it different from those used in hypertension and diabetes. Yes, treatments of these maladies are tailored based on evidence-based cutoffs of certain lab/clinical values. But the underlying diagnosis is still crucial. If you have essential hypertension the treatment is quite different from a pheochromocytoma or renal artery stenosis, but all of them are “hypertension” in the sense of producing a value higher than 120/80. Likewise with Type 1 vs Type 2 diabetes. It’s not just the blood sugar, but the context in which it appears.
    I do believe it is important to remember that our diagnostic categories are based on social constructs and may not correlate very well with true underlying physiological differences among our patients. But treating symptoms piecemeal leads to a cookbook-type approach, often resulting in poor outcome and unnecessary polypharmacy. I will also add that I see many patients in acute hospitalizations who have been poorly served by this approach, and these are the patients, disproportionately, of Nurse Practitioners, who can prescribe meds but do not have the same “indoctrination” into the medical model as psychiatrists.
    Lastly, I would add that the evidence for psychiatric treatments is extremely thin compared with other medical disciplines. We have a lot of work to do before we can practice evidence-based medicine in the way that oncologists or cardiologists do. In the meantime, we rely on our shaky diagnostic constructs with byzantine criteria to ensure that we know what each other is saying when we discuss, compare, and study our patients.
    Thanks for the thought-provoking post.

  2. About the DSM:
    The Diagnostics and Statistical Manual, the Shrink’s bible, has been around for over 50 years, and now possibly contains nearly 300 mental disorders. As a dictionary of suspected mental illnesses, many redefined diagnoses are added to this manual with each edition. On occasion, a mental disorder is deleted from the DSM, such as homosexuality in the early 1970s. Its purpose, this manual, is to assist mental health professionals to diagnose and classify mental disorders.
    Published and designed by the APA, the DSM is also used, I understand, for seeking mental diagnostic criteria to assure reimbursement.
    The DSM is organized by the following:
    I- Mental disorders
    II- mental conditions
    III- Physical disorders/syndromes, medical conditions (co-morbidity)
    IV- Mental disorder suspected etiology
    V- Pediatric assessments
    The APA has historically directed the creation of each edition of the DSM, and assigns selected task force members to create this manual.
    The next DSM involves 27 people. About 80 percent of these individuals are male, and only 4 members are not medical doctors. Most have had relationships with the NIH, and about 25 percent of these task force members have had relationships with the WHO.
    Historically, at least a third of task force members have had, or do, have often monetary pharmaceutical industry ties in some way.
    This makes sense, as about one third of the APAs total financing is from the pharmaceutical industry.
    The APA required this task force for the next DSM edition to sign non-disclosure agreements- which is rather absurd and pointless. Lack of transparency equals lack of credibility because of these agreements of the content of the next DSM. It opposes any recovery model necessary regarding such disorders, I believe.
    The DSM should be evaluated by another unrelated task force or a peer review of sorts to assure objectivity. This is particularly of concern presently, as many more are diagnosed with mental dysfunctions presently at a concerning rate- with very young children in particular.
    Dan Abshear

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