Abstract
…anyone who leaves behind him a written manual, and likewise anyone who receives it, in the belief that such writing will be clear and certain, must be exceedingly simple-minded…
Plato (427BC-347BC)
The DSM started out as a laudable idea: to increase the reliability of psychiatric diagnoses. However, through successive revisions, it has created increasing controversy and confusion. So much so, that there has been a proliferation of publications critical of it, even by leaders within American psychiatry [1–4].
DSM IV has now achieved iconic status – far beyond what had been originally intended [5]. Referred to as the ‘bible’ of psychiatrists (more so because of its omnipresence than out of respect) it is regarded as the definitive authority on psychiatric diagnosis. For instance, in the United States, it has become a central ‘cog’ in the healthcare system, one that helps determine payments to doctors and hospitals, medication ‘approvals’ [6–8] and (until federal parity legislation was recently introduced [9]) the scope of health insurance coverage. And despite DSM IV's own caveats, even the American legal system has conferred it inflated credibility in courtrooms across the country [10,11].
Alas, the DSM had fundamental flaws from its very inception: 1) it used a categorical classification that compartmentalized human psychopathology and partitioned it into distinct “disorders” 2) it discounted the subjective and inter-subjective experience that are an integral part of human life. Fundamental tenets of the DSM paradigm are now hard to fell, because of the value judgments placed on criteria, ‘thresholds’ and field trials [12].
Yet, with all its purported empiricism, DSM III (and its successors) consistently failed to guide clinicians through the permutated presentations of clinical psychopathology. Limitations intrinsic to its design ended up conveying and reifying the opposite: namely that criteria, disorders and subtypes are immutable. The polythetic approach to diagnosis also appears rather unwieldy, as evidenced by the large number of ‘Not Otherwise Specified’ (NOS) and co-morbid diagnoses seen over recent years [3]. Not surprisingly, clinicians have begun to complain about a lack of secure footing from which to formulate proper psychiatric diagnoses or treatment. As psychiatrists, the question we have to ask ourselves is how could this happen?
Prompted by administrative pressures, but driven later by its own quest for legitimacy [12–14], American psychiatry made a radical, about-turn on centuries of its own heritage. Dating back to Robins’ and Guze [15], arbitrary decisions were made to focus on inclusion and exclusion ‘criteria’, as well as course and prognosis, rather than on advancing understanding of psychopathology [16]. With the arrival of DSM III, reliability had trounced diagnostic validity as the cherished value system. Buoyed by pharmacological advances of the day, psychiatry then began aligning itself with the thinking of mainstream medicine [14,17].
In retrospect, this approach appears to have been mistaken. It was wrong to eschew a century's worth of psychopathological and philosophical enquiry, even if the aim was to dethrone the prevailing, yet admittedly unempirical psychoanalytic paradigm. After all, there were other plausible models in addition to empiricism, such as Meyer's psychobiology [18] or developmental psychopathology [19]. But, aided by DSM III, American psychiatry moved swiftly away from such philosophies, merging itself uncritically with the medical model [13]. Interestingly, and of note, it is the philosophical and intellectual challenge inherent in psychiatry that initially attracts trainees to the specialty [20].
There is now widespread disenchantment with DSM IV and, by extension, with clinical psychiatry. Clinicians commonly voice that the patient's ‘story’ has been lost [2]. Exploration and formulation that would have encouraged competing paradigms, appear to be dying arts, as the thinking of clinicians is forcibly funneled towards a narrow ‘predetermined set of symptoms [21],’ in order to assign a diagnosis. When coupled with the ‘production line’ mentality of managed care, criticism that psychiatry has become ‘boring’[21] is understandable. Research also suggests that clinicians may not even be using the DSM as intended, because its categorical approach does not align with how they actually formulate diagnoses [22]. Arguments have therefore been advanced for abandoning the DSM's atheoretical, rather decontextualized [23] approach, in favor of a simpler, inferential approach that is more commonsensical [22].
Looking back, DSM might have earned greater credibility with clinicians if it had highlighted the pathoplastic effect of specific factors on the presentation of disorders [24], and worked on a more refined lexicon, building iteratively upon accumulated and subjective descriptions within clinical nosology [25]. Further, it would have garnered greater clinical utility had it a) not marginalized interpersonal and contextual aspects of psychopathology, and b) made more effort to group clusters of common symptoms and behaviors into more prototypic syndromes (“lumping”), so as to make them more clinically recognizable (“carving nature at its joints”[3]) [26].
While blameworthy, the DSM itself cannot be blamed for ‘it all’. For example, the multiaxial system at least tries to address biopsychosocial concerns. In reality however, Axis II and IV have never been important to corporate healthcare payors. The ‘realpolitik’ message is that if it cannot be billed, it doesn't exist. In the United States, this typically means Axis I is reimbursed while Axis II and V codes are not [27]. In addition, certain diagnoses are more likely to be reimbursed by third party payors [28,29]. This, in turn, influences clinicians toward diagnosing them (“upcoding”) [30,31]. The pharmaceutical industry has also actively promoted certain disorders (“disease mongering”) [32], perhaps explaining why some disorders (e.g. Bipolar Disorder) appear far more prevalent than they actually are [30].
Unfortunately, if the DSM remains focused only on the dichotomy of ‘disorder versus not disorder’, and continues to carve arbitrary lines of psychosocial dysfunction for corporate or legal masters, then the medical model will remain the only one enshrined in global public consciousness. This may not seem detrimental for schizophrenia, but is arguably disastrous for less ‘severe’ Axis I/II psychopathology and the evaluation of childhood dysfunction, especially given concerns about re-defining ‘problems of living’ [33] as mental disorders (“diagnostic creep”) [34] and the ensuing financial impact with respect to already burdened healthcare delivery systems [35,36]. DSM V seems unlikely to change this, notwithstanding its attempts at revamping Axis II [37].
There is so much that psychiatry could have distilled from centuries’ worth of careful observation, description and philosophical enquiry. Regrettably, this is not its reputation as we know it today [38]. It therefore behooves psychiatric leaders to be attuned to the observations of practicing clinicians in the field. Perhaps this necessitates formally separating research and clinical manuals, to reflect a divergence of foci, so that prevailing research ideology is not inadvertently obscuring DSM's rightful role for clinicians. Or to review the overreach of financial and legal interests into the arena of psychiatric diagnosis. All good reasons to challenge the questionable hegemony of DSM IV.