How to Use the DSM

In my previous blog, The Missing Person in the DSM, I questioned whether the DSM diagnostic manual classifies psychiatric disorders or the individuals suffering from diagnostic disorders—Ms Smith’s bipolar disorder, or Ms Smith, a person with bipolar disorder. I noted that, following medical tradition, the manual classifies diseases—not surprising since, in a medical nosology, we expect to see hypertension and diabetes, not Mr Jones’ hypertension and Ms Harris’s diabetes.

I also pointed out that this strategy works better in a medical than a psychiatric nosology, since psychiatric conditions are more interwoven than medical conditions into patients’ personalities and lives. Both doctor and patient can more readily treat Mr  Jones’s hypertension as simply a case of hypertension than can either treat Ms Smith’s bipolar disorder as just another case of bipolar disorder.

The conclusion of these reflections is that when we follow the medical model and leave the person out of the diagnostic model, we know too little about the person. Our patients often fit our diagnostic categories rather poorly—cheap suits from the bargain-basement rack, to borrow a metaphor from the previous blog—and we are forced to squeeze them into the Procrustean beds of our existing categories—or, in the much bruited routine of DSM-IV, to individualize them with the clumsy tactic of comorbidity—or in the equally bruited promise of dimensions in DSM-5, to individualize them with dimensional scales.

So what to do? How do we return the missing person to the manual? As I mentioned in the previous blog, the WHO International Guidelines for Diagnostic Assessment (IGDA)¹ has proposed a dramatic and quixotic approach to this problem: create a narrative dimension to the manual, effectively providing each patient with a diagnostic statement that is the equivalent of a full psychiatric evaluation. This is at once a solution and a non-solution. It is to lift the full evaluation that should be part of any patient’s chart and make it part of the diagnosis.

Here’s an alternative proposal for resolving the problem of the missing person in the DSM. In a word, eliminate the problem by forgoing this expectation of the DSM. Give up your expectations that the manual should tell you what is essential in your assessment and treatment of your patient. Think of it rather as a crude guideline that, we hope, will land you in the right diagnostic ballpark—and not much more. When we have given Ms Smith the diagnosis of bipolar disorder, that’s not the end of our assessment, it’s barely the beginning. We now have to get to know her, and figure out how to conduct our treatment. We don’t expect to find her in the manual; we will find her in our consulting room.

This approach is of course good for the clinician but not for the researcher, and it flies in the face of the DSM dogma that the interests of the two groups are the same. In fact, they are not. The clinician is interested in helping Ms Smith; the researcher is interested in studying bipolar disorder. These interests of course overlap, but they hardly coincide. Debates, for example, over the criteria for a major depressive episode—whether the requirement of only 2 weeks of symptoms and only 5 of 9 of the criteria casts too wide a net and leads to over-diagnosis—is certainly of scientific importance; but it plays little role in day-to-day clinical practice.

Am I being overly cynical about how to use the DSM? Perhaps so, but I would at least argue that my suggestions do little more than reflect how we already use the manual. Clinicians have not lost the person; they just don’t expect to find him or her in the manual. Let me end with the example of a prominent, respected—and unnamed—clinician, as related by Gary Greenberg in a recent article:

I recently asked a former president of the APA how he used the DSM in his daily work.
He told me his secretary had just asked him for a diagnosis on a patient he’d been
seeing for a couple of months so that she could bill the insurance
company. “I hadn’t really formulated it,” he told me. He consulted the DSM-IV and
concluded that the patient had obsessive-compulsive disorder.
“Did it change the way you treated her?” I asked, noting that he’d worked with her for
quite a while without naming what she had.
“No.”
“So what would you say was the value of the diagnosis?”
“I got paid.”²

References
1. IGDA Workgroup, WPA. IGDA 8: Idiographic (personalised) diagnostic formulation. In: Mezzich JE, Berganza M, von Cranach M, et al (eds). Essentials of the World Psychiatric Association’s International Guidelines for Diagnostic Assessment (IGDA). Br J Psychiatry Suppl. 2003;45;S55-S57.
2. Greenberg G. Inside the battle to define mental illness. Wired, Dec 27, 2010. http://www.wired.com/magazine/2010/12/ff_dsmv/all/1.