In my previous post on American psychiatry’s new and fifth edition of its “diagnostic manual” for mental conditions, I covered the history of the previous four editions of the “DSM” which stands for Diagnostic and Statistical Manual.
I will talk of two topics in this post; first as understandable explanation of the ‘sorting science’ that lies behind how psychiatric diagnostic categories are arrived at, and, second some of the misses and one correct addition in DSM-5.
The statistical science behind the DSM from its 3rd edition onward, is called “factor symptoms cluster analysis.” Quite a mouthful but simple concept once it is parsed and enumerated, element by element.
1. symptoms: these are the cardinal signs of an illness e.g., rash bumps and fever of chicken pox for instance. For sake of explanation I will grossly simplify all this and not get into such controversies as only a few symptoms in the world of medicine are truly unique and totally specific to an illness, which is called “pathogonomonic.”
2. all the symptoms that are clinically observed to appear in someone with the illness being considered are grouped together (clustered);
3. many cases and aggregated together, the more the better as in statistical sampling, it is a basic precept that the larger the sample size, i.e., the more people that are surveyed in a public opinion poll, the more accurate the groupings will be;
4. many clinicians, psychiatrists, are involved in pooling all these cases together as no one psychiatrist could have thousands of cases active of the same kind of symptom bearing patient illness;
5. a sorting process takes place in which it is determined, often in the early days before true computerized high speed sorting, counting and grouping could be performed, by manually grouping together cases that shared the same symptoms sets;
6. a name was discussed and commonly agreed to; its more specific subtypes were worked out with the addition of ‘qualifier’ description terms such as acute, subacute or chronic to give a simplest example (but one no longer used nowadays…);
7. confirmatory field trials were the performed utlizing the resulting description diagnostic criteria sets so generated and the members of the large working DSM edition task force would meet periodically, present cases they had found within their own worlds of practice and case by case debates would ensue whether the offered case “fit.”
The end result of this laborious process which has taken years in each edition’s gestation, has been the final document/listing of names of the conditions and its condition’s listing of relevant symptoms that distinguished it.
Dr. Robert Spitzer the shepherd of DSM-III’s editions really revolutionized the way in which the psychiatric diagnoses were constructed, introducing the above described scientific, objective data and verified symptom based approach to drawing up the lists of conditions and what features and course constituted each disorder. He took a CSI television show based approach of “follow the evidence.” Previously the earlier DSMs had been to oversimplify, a listing of favorite psychoanalytic conditions such as “depressive neurosis,” which although valuable concepts that have been lost and discarded, were almost impossible to reliably describe, quantify and develop consistent features to utilize in constructing diagnostic categories. Dr. Allen Frances (of Duke University psychiatry, my old training grounds) continued this approach of playing no favorites process in being the head of the DSM-IV Task Force of the APA (American Psychiatric Association) which owns the DSM document and is responsible for its science, content, construction, maintenance and revisions.
This is not to say or imply that the previous versions of DSM were all squeaky clean, correct and totally correct. I remember one controversy in which one group of diagnostic “proposers” wanted to have a diagnostic category called the “obnoxious personality disorder.” Some felt that this was a real entity. The rest of us were appalled and struck by the idiocy of that idea and laughed our heads off. This controversy was useful in that it forced a debate on recognizing when diagnostic labels were overtly prejudicial, value judgment laden and unscientific.
The list of diagnoses grew to almost unwieldy numbers. DSM became criticized for making everything a mental illness, “psychiatrizing.” Social thinkers, writers and analysts raised the debate for years over the issue of “over reach,” saying the “widening scope” of diagnoses had gone too far. This was not an idle point. Part of the “post release” research and ongoing monitoring of the utility, accuracy of use, of the DSM document, was to see how it “played in Peoria,” how it worked in the real world. Did the diagnoses correspond closely to real illnesses patients had. Did its parameters correspond to the different versions of illnesses. Did the DSM’s psychiatric diagnostic categories predict anything? Were they consistent and accurate in short.
By the early 1990’s it became apparent that we were having an explosion of cases not seen in such numbers in previous decades in psychiatry and mental health practice. Worry grew that the DSM had overstepped its honest boundaries by creating diagnosing of conditions in weaker forms and causing such a diagnosis to be counted many more times in the real populations than actually existed. The greatest example of this was that of bipolar disorder in children, and possibly to a lesser extents the conditions of ADHD and autism in children. In those early years, the more cautious and I thought, intellectually better grounded psychiatric thinkers and practitioners, raised the caution flags about these new trends that we did not reflect reality entirely. I used to joke in training circles and meetings sarcastically that it had gotten so bad, that anyone who lost their temper was being placed on lithium willy nilly. Many so called ‘cutting edge’ psychiatrists who felt that aggressive diagnosing and treatment of the bipolar/ADHD conditions in children was acceptable noting that many of these populations were contained in the poorer populations with less access to fancier more in-depth treatments. They would state up front that medicating these children on the diagnostic assumption (as I viewed their shallow and dangerous practices) of their having these conditions was justified, since ‘it is all they are going to get and something is better than nothing.” This is a true well remembered quote from a state level child psychiatrist in another state. I have never forgotten his proud and stubborn self justification which shocked me at that time in the late 1990’s. This was characteristic of the times and was part of the then fiercely held ‘ideology’ that pervaded psychiatry. This lock step approach was made easier by the growing trends in psychiatry which I viewed and still view as dangerous and very shallow: the emergence of ;check-list psychiatry’ in which diagnosing was confirmed by the use of survey check-lists rather than preponderant clinical evaluations and interviews, collateral information and history, classroom observations, family interviews, etc. Checklist psychiatric diagnosing can be seen as the ultimate mindless extension of the symptom list basis of psychiatry diagnosing that we are stuck with until the future when some, not all psychiatric conditions will be diagnosing genetically. We still have a ‘descriptive’ diagnostic system in some ways no more advanced than the nosological (naming) systems of the late 1800’s when all this started.
Psychiatric diagnosing became too easy and took far less time when one used the “handy dandy” check box form of describing someone’s condition. This was aided and forced by the economic restrictions forced on the mental health professions by the medical insurers. Less money was reimbursed to psychiatric and psychological practitioners for each unit of time spent with the patient. Revenue went down so savvy psychiatrists responded with ever shorter sessions spent with all patients. Psychiatrists largely became ‘prescribers,’ and did ‘medication management.’ The interpersonal basis of our practice, the relationships with our clients became shallower and much more limited. In some ways the only psychiatrists who can afford nowadays to practice in the old fashioned way, are state hospital based and academic psychiatrists who are salaried and do not have to be volume driven in seeing ever higher numbers of patients. The rest of inpatient medicine, surgery, internal medicine, etc., have inflated their hospital based revenues by the dishonest practice of “up coding,” in which more billing codes for more units of reimbursement are added to the bills. More and more tests and procedures tend to be ordered and are unwittingly more the source of income. Each unit of service is billed for, an aspirin or ibuprofen tablet, use of the bedpan to exaggerate and every discrete item of care that is forwarded to the patient. This is why, to make a joke to make a point, that a pedicure in a hospital, will more expensive than the most expensive make over a person could ever have…
In DSM-5 there has been a reaction to the enlarged number of diagnoses. The Task Force for the 5th edition evidently, in my judgment, strove to pare down the number of sub-diagnoses. Two of the most obvious areas has been in autism, and then also in schizophrenia. Autism has several useful categories, the most famous of which was “Asperger’s Disorder.” Now everyone has just “autistic spectrum disorder.” This is like saying everyone drives a “vehicle,” and there is no brand differentiations, such as Ford, Chevrolet or Subaru. The entire category of schizophrenic illnesses was reduced and useful categories such as “paranoid schizophrenia,” “undifferentiated schizophrenia,” were lost. Some reasons were that we were finding that some of the categories in psychiatric illness were not supported by genetic underpinnings of those conditions that were emerging in psychiatric genetics. But such useful categories still could have been retained as helpful descriptive “quantifiers,” since any diagnostic naming system very importantly serves as a shorthand language that practitioners can utilize to quickly communicate to others accurately what they are talking about. Again the car analogy: if I were an observer to a hit and run accident in which a driver leaves the scene of an accident after killing someone, it is of no use to the police if I can only say, “he was driving a car,” and not be able to use helpful quantifiers that helps the police narrow down their search for the guilty party.
Medicine, including psychiatry, including psychiatry, are no different than any other human endeavor. We have our FADS and the DSM unfortunately in the DSM-5 appears to be the carrier of new ideological fads. For a much more in-depth discussion of these kinds of issues, I would heartily refer the reader to the well balanced book by Dr. Allen Frances MD of Duke, entitled, Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life, published 2013 by William Morrow.