In fact, psychiatrists who specialize in any one of the major subject areas in the DSM-IV seem almost universally frustrated by "their" section of the book. This is equally true of analysts specializing in personality disorders, clinical researchers in major mental illness, traumatologists and neurobiological investigators. Overlapping dimensions, or spectra, of pathology much more accurately reflect clinical reality, whether we are talking about the narcissistic/borderline personality spectrum or the bipolar, schizophrenia, obsessive-compulsive or autistic spectra. When they can, biologically oriented researchers come up with their own criteria (like the negative/positive symptom clusters in schizophrenia), while psychodynamic and cognitive-behavioral writers put forward alternative ways to look at personality function in therapy settings. The DSM-IV's relationship to all this is as a Berlitz phrase book is to the Tower of Babel.
And then there are those horrible Axes. I suppose they were designed with good intentions. They made us think always of the medical picture (Axis III) and originally tried to save a place for psychodynamics (Axis II). Today, we all know to think of the medical situation, and the Axis I=biology/Axis II=psychology distinction is blurred: patients with schizotypy have the eye-tracking abnormalities of schizophrenia, people with chronic PTSD often have borderline psychodynamics.
The Global Assessment of Function (Axis V) is good for generating the following quip: "Subtract 20 if you want to get the treatment plan approved!" And Axis IV, "psychosocial problems," shows no appreciation of the varying symbolic import of life events. These subjective judgments are not part of a diagnosis. They belong in a good narrative note with specific examples and a little originality in the use of adjectives!
Granted, there are disclaimers in the current manual's introduction about not taking categories literally and not regarding DSM diagnoses as a complete understanding of the patient. But these muted caveats do not help to reverse the fact that the DSM, by its very existence in its present form, implicitly encourages the entire mental health care system to do those very things. It is a tacit endorsement of false precision and superficial literalism in psychiatric assessment.
Two questions arise from this situation, and the first is, Why? Why maintain and elaborate a diagnostic system that no one is happy with? A skeptic need look no further than the catalogues full of DSM-IV treatment guides and companions, DSM-IV-keyed textbook editions, DSM-IV software and the like that fill every psychiatrist's mailbox. The DSM-IV is a big moneymaker for the APA. Who dares practice--indeed who can practice--without the reigning bible close at hand? I maintain that the APA is holding back the development of the profession it represents by maintaining its income and its institutional hegemony over American mental health care with the DSM system.
A final question is: What do I suggest instead? My regular readers well know that I am better at tearing down than at building, but I will try.
Researchers, of course, will always need research diagnostic criteria and are good at coming up with them. These same researchers ought to also pay some attention to operationalizing and studying the real, dirty categories that real clinicians use. This is already happening to some extent, as the pitfalls of excluding most of the patients we treat from research studies have become apparent.
The IDC-9 or ICD-10 would provide a perfectly good alternative for billing and coding purposes, and perhaps the APA could let the World Health Organization take back the job of developing future code bibles, rather than duplicating the task. While we will always need an administrative diagnostic system, the APA's resources are better spent finding ways to get people excited about--and interested in--the rich scope of the field it represents, instead of endlessly rehashing an arid and intimidating set of menus.