|It is an open secret that most psychiatrists do not use the DSM.|
Read the news and you may be forgiven for thinking there is some violent fervor about the release of DSM-5. Its arrival is apparently “long awaited” and “hotly anticipated.” Petitions denounce it. Organizations note their “concern”. Lobby groups have called it unsafe, unfit for purpose. Campaigns for the abolition of psychiatric diagnoses appear. Survivor groups issue premature pronouncements of psychiatry’s death. I’ve been wondering: who exactly has been awaiting its arrival? It’s not researchers: The National Institute of Mental Health has made it clear that the psychiatric research agenda has moved on from categorical diagnoses. It’s not clinicians: most psychiatrists do not even use the DSM to make diagnoses. It’s not insurance companies: even in the US, most payers do not accept the DSM for billing purposes. It’s certainly not patients: a new system of classification will not improve patient care or revolutionize treatment. So then, what’s all the fuss about? Does the release of DSM-5 even matter? The answer is yes, but not as a psychiatric document. What makes the DSM so pernicious is that it is a cultural document whose influence transcends not only psychiatric practice but also the Western civilization from which it originates. Each revision of the DSM rescripts and reimagines how we make sense of our experiences, reinterprets what thoughts, feelings and behaviors are socially sanctioned, and ultimately what it means to be human.
Psychiatrists Don’t Use the DSM
One of the fiercest criticisms of DSM-5 is that it will expand the borders of mental disorder and thus psychiatrists will wrongly diagnose and treat people as mentally ill. Allen Frances, former chair of the DSM-IV task force, most ardently voices this criticism. He comes across as a silly old man nursing a narcissistic injury (he was excluded from DSM-5), throwing his toys out of his pram. He makes the assumption that psychiatrists use the DSM to make diagnoses. It is an open secret most psychiatrists in fact do not! If most psychiatrists used the DSM constructs we would not see an epidemic of bipolar diagnoses in children as young as two. In fact, most of the patients who come to me with the label of bipolar disorder, do not meet the criteria for the DSM-IV bipolar disorder construct. Schizoaffective disorder, which is supposedly a rare diagnosis, is possibly the most common diagnosis I see in the charts of inpatients which is deeply suspicious. More systematic studies show diagnoses patients garner have little to do with the DSM. For example, one study in the Veteran’s Administration system suggest 25% of schizophrenia diagnoses did not meet DSM criteria, and psychiatrists often made up diagnoses so Veterans could get benefits. In the private systems, fraudulent diagnoses are given as diagnosis determines remuneration.
Most psychiatric diagnoses are not made by psychiatrists but in primary care. Most primary care physicians do not know the diagnostic criteria for most of the common mental disorders as described in the DSM, but that does not stop these labels being used. Even for some common mental disorders most psychiatrists do not know the diagnostic criteria off by heart, and even if they do, take no heed. Take posttraumatic stress disorder as an example. This is a common mental health diagnosis. The diagnostic criteria for the construct are many and complex. I would hedge that over 90% of psychiatrists do not know the diagnostic criteria verbatim. Even if they did, one criterion is than an individual responded to a traumatic event with “fear, helplessness, or horror.” I do not know of any psychiatrists who ask their patients whether they responded in one of these three legitimated ways of responded to severe adversity, and if they did, their patients would probably be puzzled. Having no immediate reaction, or feeling anger or shame instead of “fear, helplessness or horror” to rape will not preclude a psychiatrist making a PTSD diagnosis, but if you stayed faithful to the DSM-IV, PTSD cannot be diagnosed. For depression, the bereavement exclusion is going and there has been concern people will now be diagnosed with depression following bereavement. It is already happening and has been happening for years.
That is not to say that diagnostic assessments are never useful, but this goes beyond the DSM. Diagnosis is important when it comes to identifying whether the morbid mental state is secondary to a medical condition. For example, I have treated patients who present with ‘depressive psychosis’ but this is due to myxedema coma, or those who are behaving bizarrely but have a metabolic encephalopathy. It is also important to identify whether the individual has fried their brains with drugs such as methamphetamine, ‘bathsalts’, or ‘spice’ which can lead to florid perceptual distortions and erratic behavior.
DSM diagnoses no longer guide treatment
Perhaps diagnosis informed treatment once upon a time, but this does not seem to be the case today. This is at least partly true. Individuals have experiences of mental life that cause distress and lead them to behave in ways others feel are bizarre or un-understandable. As a result they may see a psychiatrist. The psychiatrist can engage in the semiotic act of making a diagnosis. In order to do that, he engages in a precursor semiotic act, which involves recoding individual experience and observable mental phenomena or behaviors into ‘symptoms’ and ‘signs’ respectively. If he stops there, he can, and often does ‘treat’ the patient. If those ‘symptoms’ and ‘signs’ are regarded as psychosis, he will end up on a neuroleptic. If the patient is seen as ‘depressed’, he may end up on a serotonin reuptake inhibitor. If he appears ‘anxious’, perhaps a benzodiazepine will be prescribed. If ‘mood swings’ are observed, lithium or an anticonvulsant will be the order of the day. Many patients have experiences that are recoded into a bewildering combination of depression, elation, irritability, psychosis, anxiety, and may end up on an ‘antidepressant’, anticonvulsant, neuroleptic, and benzodiazepine, and if there is no response, this experience will be interpreted as ‘treatment-resistance’ and another medication will be added! I would like to say that this is a caricature of American Psychiatry, but this appears to be the rule rather than the exception. This is not how I practice, and am fortunate to have thoughtful trainers, but outside the academic ivory tower and in the community rampant polypharmacy is the rule. This happens in spite of diagnostic constructs in the DSM, not because of them. Sometimes response to cocktails is even used to support a diagnosis in a backward logic. In this way the DSM is largely irrelevant to the practice of psychiatry. Systems of psychiatric classification are relevant in the consultation room more from their influences on cultural consciousness and experience of the self, than from use in guiding diagnosis and treatment.
Throughout history there have always been individuals who have been regarded as mad, or as Philippe Pinel called it, suffering from ‘mental alienation.’ For Pinel, to be mad meant one’s “character, as an individual of the species is always perverted; sometimes annihilated”. Without reason, man is no different “from the beasts that perish”. It is not madness that causes one to relinquish personhood, but to be identified as such. Psychiatrists, as the moral arbiters of mental life are thus also the high priests of personhood. Psychiatric diagnoses today extend far beyond ‘mental alienation’ and include a wide array of behaviors and experiences regarded as deviant. The removal of homosexuality from the psychiatric cannon is the best example of how personhood was restored to individuals previously regarded as pathological and deranged. For DSM-5, ‘gender identity disorder’ is being replaced with ‘gender dysphoria’. This is similar to homosexuality being replaced with ego-dystonic homosexuality before being expunged altogether. So whilst transgender individuals will no longer be regarded as mentally ill, it is a mental illness if you feel shit about it. A step to reclaiming personhood perhaps, but the transperson’s response to an intolerant society is still seen as pathological.
Far away from the locked psychiatric unit and the consultation room, the DSM exists in classrooms, libraries, the internet, the popular imagination. Each diagnosis at once hijacks personhood and redefines it. With the disappearance of Asperger’s syndrome, a cohort of socially awkward computer geeks have been disenfranchised and forced to rejoin ‘neurotypicals’ or be redefined autistic. The DSM provides the script of how we should respond to trauma; the narrative of resilience replaced with vulnerability. It is a veritable ‘how-to’ for those wanting to be anorexic or bulimic and join ‘pro-ana’ communities. It conveniently rewrites the ways we can be seen as ill, seek professional help, gain compensation, or even moral exculpation for our behavior. From Portland to Port Moresby, the DSM unites us with a global template for being mentally ill. In doing so, the DSM not only seeks to describe the landscape of psychopathology, it actively shapes it. Whilst removing the bereavement exclusion for diagnosing major depression may not change the psychiatrist’s attitude, it does refashion the cultural expectations of what constitutes acceptable misery. What is pernicious about the DSM is not how it shapes psychiatric practice directly – it doesn’t. Instead, it at once erodes personhood from those seen as ‘mad’, and for everyone else creates a cultural expectation that we are all sick and in need of treatment.