I recently experienced the odd coincidence of receiving 2 separate emails on the same morning each asking almost the very same question. . . how can I remain so high on psychiatry while at the same time being so critical of some of its recent trends and so fearful of the likely future harmful impact of DSM-5?
My answer came easily—the first thought was straight out of Hippocrates. As psychiatrists, we heal whenever we can, we provide empathy and consolation whenever we can't. Our field is blessed with powerful and varied tools—both psychotherapeutic and medication—allowing us to achieve treatment results better than those in most of rest of medicine. A majority of our patients receive substantial benefit, a substantial minority recover completely. We are good at listening, caring, and using our experiences and personalities in the privileged journey of helping others to heal, adapt, and solve their problems.
The recent explosion in neuroscience knowledge is forming a rich and solid basic science foundation for the clinical practice of psychiatry. Admittedly, the truly remarkable findings still have very limited application to clinical work, but the future is bright and we are embarked on perhaps the most exciting of mankind's intellectual explorations. The brain is by far the most complicated thing in the known universe and our field is central in accumulating an understanding of the ineluctably complex processes by which it creates mind, consciousness, and behavior. Psychiatric practice requires you to be a combination of doctor, scientist, shaman, philosopher, and healer. It is a good life and a high calling.
How does the DSM and psychiatric classification fit in? Diagnosis is the common language that starts every conversation in psychiatry. It is a medium of communication among clinicians, across the clinical/research interface, between teacher and student, clinician and insurance company, psychiatry and the law. Like all languages it is essential, but is rarely clearly right or wrong. The DSM's are no more, but also no less, than a useful convention. They could have been written slightly differently, but our current version is as good as any. Dramatic changes undertaken before we have a deeper scientific understanding are likely to do more harm than good.
Our current classification in psychiatry will someday seem quaint—just as Koch's discovery of bugs ended the diagnosis of consumption. Descriptive psychiatry has brought us just as far as it can possibly go. It is the best we can do until the neuroscience revolution translates into a deep level of understanding of psychopathology. This will be a gradual step-wise process that will require patience as it evolves over many decades—but the first steps seem ready to bear early fruit.
It is essential for clinicians to know the DSM language lest they be completely idiosyncratic and unable to communicate meaningfully. It is equally essential that clinicians not worship DSM as some kind of bible or see it as the end, rather than just the beginning of the clinical conversation. The DSM is an essential, but a very small, part of the rich enterprise of clinical psychiatry.
Psychiatry goes wrong when it over-promises and under-delivers. Not all of life's myriad problems are psychiatric illnesses. Not all psychiatric disorders are “chemical imbalance” or amenable to simply taking a pill. There is no shame in admitting that we still don't understand the causes of mental illness—the rest of medicine deals with much simpler organs, but the causes of most illnesses remain obscure. Although we have general outlines that are valuable in guiding treatment, each person is unique and each treatment regimen must be something of a trial an error experiment to custom fit the needs of the patient. If patient and psychiatrist work and think hard and put their hearts into it, something good usually happens.
Psychiatry does best when it sticks to doing what it does well. Let's treat the disorders we know how to treat in people who really need help. The greatest problem in the past 15 years of psychiatry has been diagnostic inflation and the over-treatment of people who really don't need it. This misallocates scarce resources away from those who do most desperately need and can most use our help. I fear DSM-5 because it threatens to further medicalize normality and spread psychiatry too thin.
Psychiatry is wonderful when done well and within its appropriate limits.