Beyond the Medical Model Michael E. Kerr, M.D. A debate currently unfolding within psychiatry is extremely relevant to how society thinks about human behavior and the nature of disease. This debate has been generated by an upcoming revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM), a publication of the American Psychiatric Association. The DSM describes the diagnostic criteria for a wide range of mental illnesses. Critics of the DSM argue that the causes of mental illness remain poorly understood and that insufficient scientific support exists for the hundreds of different diagnoses in the manual. But a more fundamental problem with the DSM is that it is based on the medical model. Studies of family relationships and studies of the impact of social stress on health are exposing the limits of the medical model. The medical model assumes that diseases have specific biological causes. The model works well in treating an infectious disease with antibiotics or surgically removing an inflamed organ. Despite all the many medical advances to treat injuries and to extend and save lives, the model has not been useful for explaining why two people can harbor the same pathogen but only one gets sick, or why two people can have the same type of cancer but one lives and the other dies. During the heyday of psychoanalysis, psychological factors were assumed to be the cause of mental illness. In recent decades psychiatry has aligned itself with the rest of medicine by adopting the biological paradigm as the cause of mental illness. Thus far, however, a causal relationship between specific brain pathologies and specific psychiatric diseases has not been documented. Psychoanalysis reinforced a cultural myth that people are relatively autonomous psychological entities, each motivated by particular psychological mechanisms and conflicts. These conflicts may develop based on family experiences, but ultimately reside within and motivate an individual's behavior. Family research has challenged this notion of autonomy by observing, not surprisingly, that people profoundly affect each other's thoughts, attitudes, beliefs, feelings, moods, and behavior. This research has produced a theory of human behavior called Bowen family systems theory. It is anchored in the assumption that emotional interdependence, which has been shaped by hundreds of millions of years of evolution, is a more accurate description of human nature than psychological autonomy. Another finding from family research is that anxiety is inherent in the emotional interdependence. This is because people's emotional well-being is so powerfully linked to their important relationships and because frequent and protracted disturbances in relationships are more the rule than the exception. If relationships are disturbed and anxiety escalates in a family system, predictable patterns of interacting unfold that can result in one member of the family disproportionately absorbing the system's anxiety. This could be the one a group pressures to solve its problems or one the group blames for causing its problems. This family member can experience the focus as threatening which activates his stress response systems. Frequent and prolonged activation of the stress response can trigger and sustain physical and psychological illnesses. The stress response does not cause disease, but it does activate vulnerabilities to disease including genetic predispositions. The findings from family research and stress research suggest that the theoretical framework underlying the DSM classifications is too narrow in scope. The assumption of specific causes for specific diagnoses may have to give way to discovering vulnerabilities to various types of psychiatric symptoms. The interplay between vulnerability and environmental factors in the development of a disease is not a new idea in medicine, but family research highlights the role of stress triggered by family interactions and provides a systematic way of assessing the stressors by looking at family and other significant relationship systems. People tend to resist letting go of the notion of individual autonomy and the idea that our behavior can have a profound impact on the health and well-being of others. It is difficult to adopt this view without slipping into blame and self-blame. An important distinction exists, however, between seeing the part one plays in relationship problems and viewing oneself or others as the cause of those problems. Perhaps no one thing causes cancer or schizophrenia just like no one thing causes a hurricane. If the conditions are right it happens but, if one piece is missing, it does not happen. We will continue to treat pieces in the puzzle but stepping back to view the whole cannot be anything but useful.

This comment is actually in regards to the change related to moving a single personality disorder to Axis I and potentially including traits/facets vs types. I thought based on the fact that there wasn't a specific PD forum here this would be the best spot for it. My concern is related to the lack of disclosure in regards to the psych testing industry and any potential conflicts of interest with psychological assessment royalties. For example, does the following list sound like a proposed trait and facet list, or does it sound like the scales of 2 psychological tests being sold that were authored by 2 members of the personality disorders workgroup? Negative Emotionality (Negative Temperament), Manipulativeness, Aggression, Self-harm, Eccentric perceptions (Eccentricity), detachment (social detachment), impulsivity, self-harm, cognitive dysregulation, affective lability (emotional lability), insecure attachment (separation insecurity), intimacy problems (intimacy avoidance), suspiciousness, oppositionality, submissiveness, narcissism, restricted affectivity (restricted expression). If you answered "both,"you are correct. The proposed traits/facets of DSM-5 look an awful lot like the SNAP-2 and DAPP-BQ, each of which are authored by a personality disorders work group member. Which leads me to ask, should you really be allowed to author an "assessment" of personality and then author how personality should be assessed? Why would anyone be surprised if these two lists are similar?

I am against the idea of a personality disorder axis. If we diagnose lifelong disorders it is because we have not yet found the underlying conditions of the symptoms that make up these disorders. Borderline personality disorder, for instance, is not a lifelong condition but one developed as a result of the combination of a highly reactive emotional state and a confusing/abusive early childhood.

DSM-III adopted a neo-Kraepelinian disease model which works well for severe mental illness and applied it across the full spectrum of human psychopathology and psychosocial problems.  The 5 axes were a well meaning attempt to include the complex issues in any person's case, but in practice 4 of them fall by the wayside in a rush to simplify and reify issues onto Axis-I.  Sometimes this fits, more often than not the peg is square and the hole round. DSM5 would do well to consider a more radical axial approach such as that highlighted by McHugh et al from John Hopkins University - the 4 perspectives of psychiatry - disease, dimension, behaviour, life story.  Also to somehow incorporate or make explicit the issue of multicausality-equifinality and feedbacks.  Finally to bring the baby back without the bathwater and reincorporate psychodynamic principles and knowledge that has stood the test of time and is finding neurobiological empiricle backing in research grounded in attachment theory. A complementary classification system - the Psychodynamic Diagnostic Manual, PDM, does a better job of addressing these difficult philosophical issues and should perhaps be used in conjunction with the DSM. The DSM5 committee could consider going back to the drawing board and accepting the whole model implied in DSM-III was superficial and inadequate.  If the task of full explanation in diagnosis is too complex, alternatively DSM could rediscover a humbler place as it's predecessors the PSE and RDC were - as guides to descriptions of phenomenology and syndromes, as relatively reliable nomenclatures with heuristic value to aid clinical communication and research - and not the be-all and end-all of what psychiatric suffering means in any particular individual.

As someone who teaches novice clinicians about diagnosis I am very concerned about the proposed changes to the Multi-Axial system.  I find that it helps clinicians be thorough and thoughtful in the diagnostic process.  I especially value the differentiation of Axis II as a place to describe long-standing patterns and developmental "stuck points".  The proposed DSM5 system seems likely to  have very low clinical utility and would be highly unreliable across users because of both its complexity and the variable levels of training of users.  I find the Clusters on Axis II have high utility and reliability when teaching novices to diagnose and they have "face validity"when viewed as a developmental continuum.  I think "collapsing" the Axes is a very poor idea and will contribute to confusion and misuse of the DSM system.