Let us make a tour of some of the diagnostic categories we all use and abuse. Schizoaffective disorder comes immediately to mind. Some argue that schizoaffective disorder should be a rare diagnosis. As unhappy as I am with the DSM-IV description, they reach an opposite conclusion to my own. Rightly criticizing the arbitrariness of the current criteria for this disorder (two weeks of hallucinations or delusions in the absence of prominent mood symptoms, but prominent mood symptoms for a "substantial portion" of the illness), one authority has even speculated that the confusion about schizoaffective disorder deters medical students from entering psychiatry!
I rather think that it is today's incarnation of the DSM, the DSM-IV, that deters medical students from entering psychiatry. Strict diagnostic criteria (which some want to repair by making them still stricter) reflect neither biological nor clinical reality. These realities simply will not yield to anyone's desire for precision. On the research front, recent studies suggest that there is considerable overlap in the genetic vulnerability for schizophrenia and for bipolar disorders. What is the point of false precision when the genes themselves are imprecise?
And when I make my weekly visit to the revolving-door world of Mental Health Clinicland, where brief med checks are the usual context for my best efforts, schizoaffective disorder is among the most common diagnoses I make. One reason, of course, is that reliable histories of precisely defined symptom clusters and periods of time are usually impossible to obtain, while many of my patients have both psychotic and mood disorder features most of the time, fitting neither of the DSM-IV's clear bipolar or schizophrenic pictures.
Another reason is that the clinical syndromes we treat, whatever their genetic underpinnings, are themselves changing. If the reader will permit a brief digression, the schizoaffective debate reminds me of debates over whether black lung disease was a real illness when I was in general practice in East Kentucky years ago. Some physicians, particularly those hired by mining companies' liability insurers, held that it was simply chronic obstructive pulmonary disease (COPD). Indeed, most of the miners who suffered from it were also smokers. But the fact was that black lung behaved differently than typical COPD. At least in my care, it seemed to have a restrictive, as well as an obstructive, nature and needed more and earlier steroid treatment. These men had spent their lives breathing coal dust.
Today, our young bipolar patients are spending their lives ingesting antidepressants, cocaine, methamphetamine, methylenedioxymethamphetamine (MDMA) and hallucinogens over prolonged periods. These chemicals change their brains, just as coal dust changes lungs. Inter-episode recovery, a hallmark of classic bipolar disorder, becomes a thing of the past. Delusions, hallucinations and mood-cycling become entrenched, and antipsychotic maintenance essential. I could try to be strict and pile up two or three Axis I diagnoses to describe this entity, thereby confusing everyone else involved in the patient's care. Instead, and with no apology, I call it schizoaffective disorder, which is more easily explained to nonpsychiatrists as a nonhomogeneous in-between category.
One can leaf through the DSM-IV and find countless howlers and paradoxes, as I am sure many readers have already done. More important are major problems like the relationship of narrowly defined posttraumatic stress disorder to the commonly found clinical entity of "chronic complex PTSD," which includes mood-cycling, dissociative and/or psychotic features, and predictable personality and boundary derangements. Again, we need to pile up several Axis I and II labels to strictly diagnose--and obfuscate--a familiar clinical presentation.
Aside from conversion disorder, the somatoform disorders are a mess (four pain symptoms, two gastrointestinal symptoms and so on). Primary care physicians never use these diagnoses, instead sticking with the clinical presentations they see, such as fibromyalgia syndrome. Anxiety disorders are artificially separated from the mood and psychotic disorders with which they are usually intertwined, yielding the frequent question, "If I have an anxiety disorder, why are you treating me with an antidepressant?" How many cases of pure generalized anxiety disorder have you seen? Of isolated social phobia? And so on.
The personality disorders section, categorical as it is, has been very effective in stifling nascent psychodynamic thinking among our trainees. Many of these "disorders" are extreme forms of various dimensions of normal personality. Their very extremeness is often, indeed, state-dependent with regard to other psychiatric illness and general stress level. The truly dynamic aspects of some of the more interesting ones, such as narcissistic and borderline personalities, have been bled out of the DSM categories. For example, a "deflated" aspect of narcissism, which presents with outward "low self-esteem" around a grandiose core, exists in variable equilibrium with the outwardly grandiose aspect described in DSM-IV, wherein it is nowhere to be found (see my essay "The Endless Walk of the Fool" in The Thaw [The Analytic Press, 2002]). And although observing how these character-disordered patients respond in treatment is the sine qua non of psychodynamic diagnosis, fundamental descriptions of such responses, such as the discussions of borderline personality organization by Otto Kernberg, M.D., are omitted.