Leading psychiatrists question psychiatry's diagnostic manual

With the new American Psychiatric Association Diagnostic and Statistical Manual V (DSM V) slated for publication next year, leaders in American psychiatry are criticizing the volume as unreliable.

The DSM is the compendium of conditions psychiatrists use to diagnose their patients and, to a great extent, determine what treatments would benefit them.  The DSM also has extremely important implications for what kinds of psychiatric problems insurers will cover and even which ones schools and employers will consider disabilities.

Dr. Allen Frances, professor emeritus at Duke University, who was actually the chairman of the DSM-IV task force, asserts in a recent blog published that the clinical trials that supposedly determined whether the new DSM V is a good and accurate guide “have been a pure disaster from start to finish.”  He calls the trials a “fiasco” and accuses the American Psychiatric Association of having “lost its competence and credibility.”

Frances is by no means the only critic of the DSM-V.  I have written before that advocates for those with autism have expressed grave concerns that the new guidelines proposed to diagnose that condition could leave out 10 to 45 percent of those currently diagnosed with the condition, leading to millions of children having no insurance coverage related to it.

But Frances alleges much more.  He cites data that indicates that the DSM V signs and symptoms that are proposed to define Major Depression and Generalized Anxiety Disorder are unacceptably inaccurate.  And he worries that the official journal of the American Psychiatric Association, the American Journal of Psychiatry, which published a positive review of the DSM V has been “forced into the role of a cheerleading house organ, not an independent scientific journal.”

Given the concerns of leading psychiatrists like Frances, with whom I happen to agree, it is time to give real consideration to fundamentally changing the way psychiatrists use the DSM and encouraging them to think much more about what caused the disorders they are diagnosing.

This is the proposal of one of the most influential psychiatrists of our time, Dr. Paul McHugh.  McHugh is Chairman Emeritus of Psychiatry at Johns Hopkins.  He and his esteemed colleague Dr. Phillip Slavney have written in the New England Journal of Medicine that the DSM is just a list of conditions with signs and symptoms and offers “no way of making sense of mental disorders.”

Making sense of mental illnesses—describing the patient’s actual suffering and disability—is imperative because pretending that people can be understood by giving them a label like major depressive disorder misses the fact that many actually complain mostly about anxiety, many others are actually grieving the loss of a loved one, and many others have pervasive low mood, low energy and low self-esteem that came “out of the blue.”

McHugh and Slavney correctly wonder whether this sloppiness in simply labeling rather than truly understanding patients explains why antidepressant medicines—if they are being given to a very diverse group of people artificially lumped together by the DSM—don’t seem to work much better than placebo.  Why would they, if half the people who meet the criteria for major depression actually have other, central issues to address?

Focusing on causes would reawaken psychiatry’s commitment to looking at people’s life stories as relevant to their suffering.  It seems strange to say it about a profession based on insight, but too many psychiatrists practicing today don’t know a lot about their patients’ lives; they choose diagnoses from the DSM and pick which medicines corresponds to it.  That isn’t treating the person.

McHugh and Slavney say it is time to enrich and augment the checklist method of making diagnoses by starting to group mental disorders into the underlying causes:  [roughly translated from their wording] brain diseases, personality problems, behavioral problems and life stresses.

The McHugh and Slavney perspective is a valuable one.  Given the rising chorus of concern about DSM V, their thoughts, as well as those of Dr. Frances and of autism advocates and of many others should translate into delaying publication of the DSM-V, until it can incorporate a new respect (which is a very old idea, indeed) for how patients got sick, to begin with, and how, therefore, they can get well.