A case of ‘cardiology envy’?

Wave an ECG under the nose of a cardiologist and more times than not, they will be able to distinguish atrial fibrillation from atrial flutter. Ask them to listen to a murmur and they will invariably be able to differentiate tricuspid from mitral regurgitation. These diagnostic skills may be coveted by clinicians in apparently softer specialty areas, such as psychiatry, and lead to an inferiority complex. In the world of academia, researchers from the social sciences are often said to have ‘physics envy’ when they attempt to validate their discipline by inappropriately including mathematics in order to imitate the natural sciences. Perhaps the increasing trend in psychiatry to label mental illness into distinct categories is the equivalent to this in clinical medicine. I propose that it may be a case of ‘cardiology envy’.

The recent publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has introduced a number of new codes and has renewed the debate about how mental illnesses are diagnosed and catalogued. Since the manual was first devised in 1952, there has been a clear move towards categorizing mental illnesses into distinct diagnostic codes. However, there has been much controversy about the value of these classifications, with many psychiatrists expressing concerns about this approach. Most recently, the debate has also spread to the general public, with the introduction of new codes in the DSM-5 such as ‘internet addiction’ and ‘hoarding’ sparking much media interest.

One of the main criticisms of the manual is the potential that it has to lead to overdiagnosis. The application of universal criteria may lead to many states that are part of the normal human experience being inappropriately defined as mental illness. Indeed, the use of standard diagnostic criteria has led to tick-boxing screening exercises being widely used in primary care settings, which often label the unhappiness associated with everyday life events as clinically diagnostic for depression.

Mental illnesses are complex and often have social, behavioural and biological components. The relative importance of each domain varies among individuals and must be carefully elicited from a skilled clinician, who must be focused on gaining a deep understanding of the individual in order to contextualize their presentation. The unique nature of this process means that finding a suitable code may be both unfeasible and undesirable. Moreover, the ability to reach this understanding is an enormously complex skill that can take years of experience to master. Applying universal diagnostic codes should not be necessary to validate the difficult task of assessing patients with mental health issues.

Defenders of the DSM-5 argue that prior to the existence of the first handbook there was no international agreement over the defining features of common mental illnesses, such as schizophrenia. Critics, meanwhile, argue that this emphasis on classification is unhelpful and indeed can be potentially destructive and stigmatizing for patients. The British Psychological Society, for example, responded to the DSM-5 by recommending a new approach to mental illness that acknowledges the ‘overwhelming evidence that it is on a spectrum with “normal” experience, and that psychosocial factors such as poverty, unemployment and trauma are the most strongly-evidenced causal factors’.¹

There have been various attempts to explain why some psychiatrists have sought to pursue this coding approach. It has been suggested, for example, that psychiatrists on the DSM-5 and other panels may have sought to champion the cause of conditions they have a clinical or research interest in. There may also exist a deeper need among the specialty to validate their clinical work and create a more scientific environment. Regardless of the factors driving this approach, the DSM-5 has highlighted many controversies in the evolution of psychiatry as a clinical discipline. It is clear that the diagnosis and management of mental illness requires an extraordinary amount of skill. However, the very complexity of the specialty lies in the individuality of each presentation. Psychiatrists should not need to apply endless diagnostic codes in order to be recognized as being skilled and expert clinicians.