Therefore, psychiatrists cannot ignore the new manual and go about business as usual. They must adapt, especially if they want to be sure that their patients keep receiving affordable treatment. Yet this diagnostic bible is a work in progress. In fact, although the revisions are 90 percent complete, the APA may still make significant changes and even delay the book’s official release. Even after its publication, the DSM will remain a snapshot of a field in flux—an ambitious attempt to capture an evolving, often ambiguous science.
Diagnosing the DSM
Psychiatrists have been kicking around the DSM-5 in a scientific scrimmage that dates back to 1999, when the APA and the NIMH sponsored a meeting to jump-start planning. More than 13 joint conferences later, committees of psychiatrists and psychologists have churned out dozens of white papers outlining how best to overhaul psychiatry’s bible. In April 2006 the APA appointed clinical psychologist David Kupfer and Regier as chair and vice chair, respectively, of a team of 27 scientists assigned to digest the research literature and propose revisions to this historic volume.
Right away researchers fingered several major failings of the DSM-IV. First, many of the symptom checklists were so similar that many patients left a psychiatrist’s office with several official diagnoses rather than just one. It is unlikely that large numbers of patients each have a variety of different disorders, says Steven Hyman, a task force member. Rather, he suggests, a single cognitive or biological process—maladaptive thought patterns, for instance, or atypical brain development—may manifest itself in symptoms of more than one ailment. To address this problem, curators of the new book eliminated over a dozen less distinct disorders, in some cases merging them into larger categories of illness, such as the autism spectrum [see “Psychosis Revisited”].
Patients and their psychiatrists often struggle with the opposite problem, too: a person’s symptoms might be fewer or milder than those listed in the DSM or simply do not match any disorder in the manual. As a result, psychiatrists slap large factions of their clientele with a “disorder not otherwise specified” label. The most frequently diagnosed eating disorder is “eating disorders not otherwise specified.” The predominant autism spectrum disorder? By most estimates it is “pervasive developmental disorder not otherwise specified.” The third most common personality disorder is, you guessed it, “personality disorder not otherwise specified.” Health professionals rely so heavily on catchall diagnoses because the current DSM has some serious gaps in its diagnostic offerings and has some superfluous entries.
In addition to eliminating ailments, the DSM-5 will encourage psychiatrists to collect more detailed information about patients’ symptoms. With more data to consider and more complete descriptions in the manual, the theory goes, psychiatrists are more likely to find a proper match between a patient and an illness.
Degrees of Dysfunction
To improve diagnoses, the DSM-5 asks doctors to grade the severity of their clients’ symptoms. A verdict of major depression, for example, will include a rating for each symptom—insomnia, say, or thoughts of suicide. Similarly, a child who is diagnosed with attention-deficit hyperactivity disorder would also receive an assessment of her ability to focus, ranging from poor to excellent.
This ideological shift signals a step away from the simplistic notion that mental illnesses are discrete conditions wholly distinct from a healthy state of mind. Instead the new volume reflects the idea that everyone falls on a spectrum that stretches from typical behavior to various shades of dysfunction. Where you land on that scale determines whether your symptoms merit treatment. This approach might assist, for example, psychiatrists evaluating a patient’s attention problems, which can seem almost ubiquitous in younger children. Considering an individual in the context of others can make it easier to flag the neediest cases. Psychiatrists, of course, already use many scales and questionnaires in their practice. The DSM-5 will standardize such ratings so that doctors use the same scales to measure a given disorder and increase the chances they will reach similar conclusions about comparable patients.
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22 Comments
Add Comment"Although many psychiatrists do not sit down with the DSM and take its scripture literally..."
Reply | Report Abuse | Link to thisThis is an important caveat. And it illustrates why more attention needs to be drawn not to what's in the book, but how the book is used.
As a practicing psychiatrist, I agree with you that many clinicians "rely on personal expertise to make a diagnosis." What we are forced to write in the chart, however, is dictated by the DSM. From that point on, the diagnosis-- NOT the patient-- becomes the focus of treatment. It serves as a gateway not only to a wide range of social services-- which could be beneficial-- but also to a potential lifetime of medication trials and other ill-advised treatments.
Most psychiatrists view the DSM and the diagnostic process as a necessary evil: "necessary" for reimbursement and to be able to help the people who seek our assistance, but "evil" because in many systems the assistance we provide is dictated by the diagnosis, not by the unique needs of the individual.
"Residual: very few typical symptoms but some odd beliefs or unusual sensory experiences."
Reply | Report Abuse | Link to thisThat describes most of the people I know.
The DSM is nothing more than a piece of trash. These so called conditions were made up from a committee of "scientists" the majority of whom have financial connections to drug companies. These companies are drooling over the fact that new markets will be open to them to sell more worthless and harmful drugs. There is absolutely NO scientific basis for the conditions included in the DSM. This is nothing more than a sham to make insurance companies pay for more drug therapy at an astronomical increase in cost.
Reply | Report Abuse | Link to thisQuote: In the past the APA has received harsh criticism
Reply | Report Abuse | Link to thisAnswer: "I have lived a full, interesting and creative life supported by my family and many friends and irritated and spurred on by the hostile criticisms of a group of psychiatrists representing APA and NIMH."
Those words were spoken by Dr. Abram Hoffer , 'father of Orthomolecular Psychiatry'.
http://orthomolecular.org/history/hoffer/index.shtml
"Catatonic schizophrenic"
"Left in a coma and was dying"
"The next day he sat up and drank it and thirty days later he was well. He was discharged and remained well"
The American Psychiatric Association advocates AGAINST the use of the treatment above.
The American Psychiatric Association MUST be harnessed and their powers removed.
So, ironjustice, all you have is a story from the website of orthomolecular.org itself?
Reply | Report Abuse | Link to thisEven if it's true, it occasionally happens that people wake up from a coma for no discernible reason. One case is not statistically significant.
"Schizophrenia is characterized by a tenuous grasp of reality, difficulty thinking and speaking clearly, and unusual emotional responses."
Reply | Report Abuse | Link to thisCan we use this diagnosis for political parties? Pretty please with sugar on top?
But seriously. Opening the process is probably a good thing. But does it go far enough? AFAIK, the DSM was originally a collection of random wisdom from a bunch of doctors. It was unexpectedly a best seller. Arguably, it's long past time to put some science into it. One hears phrases like "evidence based medicine". How would that work with the DSM? Maybe pilot projects. One publishes a DSM for Wayne County, and another for Macomb County. Figure out the pluses and minuses of each through use, and apply the results to the next pilot projects. Results are only expanded to larger populations when the desired outcomes are maximized. No politics. No vested interests. This isn't easy, but it appears that there is a mandate.
If religion had to undergo as massive and dramatic an overhaul as this, devotees of "science" would roundly denounce it. In fact, "psychiatry", "psychology", "psychoanalysis" all have traits that utterly disqualify them much less than as "scientific", but even as useful. Consider that all "psychoanalytic theories" are definitively different, if not wholly incompatible. Freud's emphasis on sex, Fromm saying a desire for conformity and programming defines man, Skinner saying everything is already programmed, Jung invoking already defined stereotypes. And all supposedly describing the same human mand! And yet no devotees of "science" attack "psychology" as a fraud! They respect the money, not ethics! Just as in the case of the single most accusatory quality of "psychoanalysis". Claiming to be a modeling of all human minds, "psychoanalytic theories" all derive solely from case histories! All "psychoanalytic theory" is based on individuals with proven mental instabilities, yet, they try to generalize from these to healthy minds! No "psychoanalytic theory" recognized by "science" derived from interviewing sane people!
Reply | Report Abuse | Link to thisDave , there is no room to place much of his 600 published works. The fact you seem not to know anything OTHER than that which I have placed , one article , means ? You don't have the gear to be commenting.
Reply | Report Abuse | Link to thisWhat evidence do you have of this alleged interference from drug companies? That's a strong accusation to make blindly.
Reply | Report Abuse | Link to thisI've often thought it's very ironic that "science-based" critics of alternative medicine ignore therapists and psychologists, who *really* have little or no research support for much of what they do. Psychiatrists might practice somewhat more science-based medicine, but still deserve criticism from a science-based point of view.
Reply | Report Abuse | Link to thisQuote: what evidence
Reply | Report Abuse | Link to thisAnswer: Depakote.
600? So? L. Ron Hubbard published far more.
Reply | Report Abuse | Link to thisQuite the generalization, that is.
Reply | Report Abuse | Link to thisQuote: L. Ron Hubbard published far more
Reply | Report Abuse | Link to thisAnswer: Typed that name into Medline. No hits.
A good companion to the DSM is the "Psychodynamic Diagnostic Manual". This book informs us about the patient rather than the diagnosis. It is linked to the DSM classification of disorders and so provides us with an informative complement to the DSM.
Reply | Report Abuse | Link to thisThe DSM5 comment process as diagnostic tool - fifty million comments, mostly critical, from half a million individuals. Average 100 comments per individual. I'd guess most sane individuals probably commented 1, 2 or 10 issues. I hope they gave no weight to the comments of those who submitted hundreds or thousands.
Reply | Report Abuse | Link to thisIt's "Psychology's," not "Psychiatry's." Psychiatrists mainly dispense meds. In fact, psychiatrists are required to have no psychological training. Psychologists use the DSM a whole order of magnitude more than psychiatrists. I'd expect SciAm to get that right.
Reply | Report Abuse | Link to this-Dr.Bunny
As someone who has worked in this field for 40 years and been psychoanalyzed, trained first as a Rogerian, then a psychoanalytic, then Eriksonian and lastly CBT therapist; worked in an acute inpatient setting, a multidisciplinary outpatient setting, for a managed care insurance company, doing admissions for an facility and currently working in an outpatient practice group I can say that the DSM is an important tool. It does not capture the unique individual in the room but it provides a framework for organizing ones thinking about that person.
Reply | Report Abuse | Link to this"Suspiciously, between 40 and 60 percent of all psychiatric patients are diagnosed with a personality disorder, hinting that symptoms of at least some of these “disorders” resemble typical behavior too closely."
Reply | Report Abuse | Link to thisI think that often a doctor will add on a personality disorder because the diagnosed clinical disorder does not contain all the patient's relevant symptoms.
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I'm glad concepts like severity and behavior spectrums are starting to be introduced.
There is a catch 22 especially with anti psychotic medications. After you have been on them for months and seek to withdraw from the medication the withdrawal side effects are exactly the behaviors that supposedly were diagnosed in the first place and then some. Anti psychotic drugs cause an even greater chemical imbalance in the brain than actually existed at the time of the diagnosis and treatment. Withdrawal from anti psychotic drugs makes you even crazier than when you first started out with the medication.
Reply | Report Abuse | Link to this"What evidence do you have of this alleged interference from drug companies?" Is that Musclefox of fox tv.? All aspects of US society are controlled by Corporations. The FDA and Dept of Ag. are run by Monsanto, Condoleezza Rice went from Exon to Secretary of State for Bush/Chaney's OIL WAR Industry, The Dept. of Energy historically by Coal ,Oil and Nuclear Industries Retirees ,The Senate Watch dog on Internet Porn gets busted with young boy in public restroom, What Govt. agency is not run by 'the fox guarding the Hen house'. Corporations Make the rules Americans have to live by. The People have no voice, not in the White House,Congress, or the Corporate Media, Against them.The Pharmaceutical Companies keep America the Most Doped Up people in the World. What evidence do you need ? If you will not believe FACTS ! But You won't hear that on Fox news.Occupy Truth ! Freud was a Fraud which Drug Companies Perpetuate through Funding of 'University Studies' .
Reply | Report Abuse | Link to thisSeveral stupid police officers in Western Australia just recently abducted some innocent guy off the street in Perth, and handed him over to psychiatric staff from Graylands Hospital, who then promptly injected him with a powerful drug to sedate him, ignoring his protests all the while. This innocent guy had an immediate adverse reaction to the drug and had to be hospitalised at a major hospital. It turns out that this poor fellow was mistaken for a psychiatric patient who'd absconded from Graylands where he'd been in psychiatric care for approximately eight months, yet the extremely "lax"[read as: stupid] psychiatric staff were unable to positively identify the patient being sought and thought that this guy will do since he's being given them by the police. He was securely handcuffed after possibly being roughed-up by the police to boot. This just shows how inadequately putatively trained psychiatric staff keep their patients under observation and typifies how they're also unable to assess the mental condition of any person adequately, just like the myriad psychiatrists involved with the fiasco that occured during the "Rosenhan Pseudopatient Experiment" in the United States of America. The Graylands patient who was still being sought presented himself back at the secure ward several days later, entirely of his own volition.
Reply | Report Abuse | Link to thisUntil such time that we are provided with something far superior than just the fallible human brain with which to assess any person's mental condition, present-day psychiatric assessments are about as futile as the endeavour of an inept businessman who doesn't advertise. This inept businessman, because he doesn't advertise his business, is just like the guy who winks at a pretty girl in the dark. He knows what he's thinking...but nobody else does! Maybe he could do better working as a psychiatrist?