America's Diagnostic Bible - The DSM
The most common, widely used and nearly mandatory diagnostic system in the United States is the Diagnostic and Statistical Manual of Mental Disorders (commonly referred to as the DSM). The DSM is published and controlled by the American Psychiatric Association (APA) and has been promoted by the APA as a technological triumph that is based on data and science. The American Psychiatric Association is not the same organization as American Psychological Association (also known as the APA).
The organization and the structure of the DSM presents an image of precise and exacting criteria that can be used to formulate the diagnosis of a mental disorder. This level of precision and the criteria have persuaded many professionals to conclude (without critical evaluation) that the DSM identifies and describes clear and distinct disorders and does so in a manner that is useful and beneficial to professionals and consumers.
The DSM does have merit. When correctly used, the DSM is very highly reliable. But this just means that a group of professionals using the DSM will often reach a similar diagnosis. The concerns expressed by scientists and practitioners are that the conclusions, although reliable, are often wrong and may do more harm than good.
There is considerable overlap among diagnostic categories in the DSM and it is possible to reach a more desirable or less desirable diagnosis depending on the evaluator. Even when there is agreement, many professionals are becoming concerned that the diagnoses and conclusions that follow from the DSM are not very useful. In other words, the diagnosis reached is not much more than a label that is based on an arbitrary set of symptoms. Most of the time a DSM diagnosis does not indicate the best course of action or even what treatment is necessary.
More and more managed care companies are asking professionals to make a diagnosis using the DSM and to provide treatment in a systematic and cost effective manner. For example, if your symptoms fulfill the criteria of a major depressive episode, then managed care wants to know what treatments and/or what drugs should be used for that diagnosis.
Unfortunately there does not appear to be any clearly useful relationship between the DSM diagnosis, treatment and the outcome of treatment. For all the apparent precision and reliability, the DSM diagnostic system minimizes one important fact. The DSM was not constructed scientifically but is based on a consensus building process that is highly political, partially democratic and even resistant to scientific evidence. The mere fact that any diagnostic system is reliable does not mean the process is valid, useful and not harmful.
Another important scientific observation has been the finding that very similar symptoms and behaviors that will result in a specific DSM diagnosis can have several entirely different causes. More importantly, for each cause there can be an entirely different treatment. Diagnosis using the DSM does not indicate what treatment is necessary. The differences between people and their social environments can have a dramatic influence on how symptoms are expressed. A similar source of a problem can be expressed in very different symptoms and behaviors. Culture and ethnicity are powerful moderators that strongly influence how people behave and how symptoms are reported and even experienced.
The diagnostic process employed by the DSM is nowhere near the quality and sophistication of the diagnostic process in medicine - and many physicians argue that the medical diagnostic process is not sufficiently reliable or valid. And while there are similar diagnostic processes in medicine, most medical diagnoses are at least based on objective findings and scientific methods. For example, the diagnoses of the various forms of cancer are based on the observation of distinct physical structures and biochemistry that vary. The diagnosis of pneumonia is based on a bacterial or viral agent of which each have fairly distinct symptoms, histories and responsiveness to treatment. Hypertension is identifiable based on numerical measures of blood pressure and deviation from a numerical norm.
There are only a few areas in medical diagnosis that are based purely on the patient's subjective complaints or vague medical terms. The overall diagnostic process employed in the DSM is not much more sophisticated than those used to reach the most general diagnosis of headache, a stomach ache or inner ear problems. There are many forms of headaches, stomach aches and inner ear problems. There are many things that can cause a headache - a tumor, tension, injury, disease, flu, allergies, a cold or bacterial infections etc.. In mental health, no matter how rigidly we use DSM diagnostic criteria, or how sophisticated the interview process, we are still looking at patterns that have many origins. There can be many sources and causes of a particular problem. For example, one type of traumatic experience can result in many different problems. As a result, there are many potential outcomes and treatment approaches that can vary with each individual, their beliefs, values, attitudes, culture, ethnicity and their resources.
Mental health professionals can rarely make a diagnosis based on identifiable changes or deviations in the structure or functions of the human body. With the exception of injury, aging, disease or forms of poisoning, very few mental health problems are medically related. Depending on who you ask, between 70 and 90% of all diagnoses are the result of social, psychological and cultural factors that influences our lives. In sharp contrast, the pharmaceutical companies, which support a great deal of research and medical training, generally promote the assumption that disorders are the result of defective biology or genetics. But even when problems are psychological, drug companies promote that disorders can still be treated safely and in a cost effective manner with drugs as an alternative or as as an adjunct to psychotherapy.
Other issues created by the use of DSM are more subtle, but they are real and they are important. For one thing, some professionals are losing sight of the patient as human being. They are also losing site of the diagnostic labels and the impact on patient rights and the risks associated with using health insurance. Professionals can become involved in a diagnostic process that does little more than expose consumers to significant risk in order to generate an authorization for payment from a managed care company. Of greater concern is the growing pressure by managed care to treat the symptoms of a DSM diagnosis and not the patient. The lifestyle, values and process that creates or sustains a patients distress are ignored when the focus is on management or reduction of DSM defined symptoms. In the world of managed mental health care there is a growing emphasis of quick diagnosis and the treatment of symptoms and not the causes. When the initial set of symptoms are initially managed, the underlying cause may be missed. For instance, a cyclical mood disorder, such as cyclothymia, can co-exist with another diagnosis such as obsessive compulsive disorder or rare hormonal condition.
The growing emphasis on DSM diagnosis has made the practice of counseling, psychotherapy and evaluation intricate, superficial and complicated, as well as increasingly meaningless to managed care, professionals and consumers. Patients should find no real comfort in a diagnosis that is reliable and specific if there is no real relationship to appropriate treatment, the outcome and quality of life.
Copyright 1999-2004, Michael G. Conner