Robert E. Kay, MD

The  mental health professions are currently awaiting the American Psychiatric  Association’s newest version of the Diagnostic and Statistical Manual. The need  for a fifth revision underscores the lack of satisfaction within the  professions with our diagnostic schema. In this article we address several  issues that have troubled us in the past versions and seem likely to do so in  the forthcoming edition.

In  modern medicine, there has been what is labeled as the laboratory revolution.

  This stresses that verifiable biologic and chemical finds in the  laboratory contribute greatly to diagnosis and treatment. However, it is  abundantly clear that no such markers exist in the sphere of emotional  disorders.

Lacking  such markers, past diagnostic manuals have consisted of lists of symptoms  grouped into syndromes with the groupings done by committees that were far from  unanimous. In past editions, diagnoses have been shifted from one axis to  another and definitions have changed. Therefore, there is good reason to  question the validity and reliability of the resultant coding.

Specific  diagnostic codes imply that these are discrete and separate entities. In  practice, the boundaries are fuzzy and allow for much overlap and results in  the listing of comorbid conditions. In physical medicine, comorbidity refers to  conditions (diseases) existing at the same time but that are independent of the  primary diagnosis.

Consider  a patient presenting with strong compulsive behaviors who periodically  experiences marked anxiety and bouts of depression. Most clinicians, even of  differing theoretical orientation, would consider these to be intimately  related. In the mental health field, comorbidity does not mean discrete  separate issues but is a way of including mention of related aspects of the  patient’s distress. Some view comorbidity as an artifact of the diagnostic  system.

A  third troubling issue is what we describe as fluidity. People change over time  in their modes of adaptation. A diagnosis is akin to a photograph. It may be  accurate but it is also static. The very next frame would show a somewhat  different picture. It is not uncommon to consult with a patient who has seen  other therapists. The patient may currently show all the requirements for a  diagnosis of depression. A report from the first practitioner offered the  diagnosis of generalized anxiety disorder.

It  is not usually a matter of one professional or another being right or wrong.  Possibly both correctly categorized the patient as he/she was at that time.  Presenting symptoms often change over time as part of the patient’s continuing  efforts at adaptation and defense.

Concerns  about the variability (weak reliability) and essential validity have inclined  some to favor abandoning the concept of diagnosis. But, to be replaced with  what? It is on this issue that the current authors differ. One of us (J.F.)  believes that even with these constraints, diagnoses have utility. They enable  practitioners to communicate some shared ideas about patients. They are used in  research and in relation to insurers and governmental agencies. The task is to  refine our schemes.

While  a complete explication of the etiology of emotional disorders seems quite  distant, it remains a worthy goal. As the professions make progress toward  understanding the genetic predispositions and the impact of psychological  trauma at various developmental stages, it might be possible to conceive of a more  tailored therapy for these disorders. One such effort is the Psychodynamic  Diagnostic Manual.

  might provide commonalities upon which to build a richer diagnostic approach.

The  other of us (R.E.K.) feels that while diagnoses have utility, there will  probably never be clear “markers” as found in general medicine and that the  idea of “chemical imbalances” or “neurotransmitter problems” is highly  speculative.

 The mental health field establishes so-called  diseases out of patient behavior and reports; both are prone to conscious and  unconscious distortions. Thus, it would be better to give up on establishing  etiology and deal with what the patient presents.

We  reunite on the important notion that the combination of psychotherapy,  carefully used medication, and environmental manipulation stands a very good  chance of helping people (not disease entities) lead more satisfying and  effective lives.

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Kendall R, Jablensky A.  distinguishing between the validity and utility of psychiatric diagnosis. 

Sobo S. A Reevaluation of the Relationship Between  Psychiatric Diagnoses and Chemical Imbalance. 1999 Grand Rounds of University  of Alabama Medical School.
  

 Maj M. Psychiatric  comorbidity: an artifact of current diagnostic systems. 

Silver Springs, Md; Alliance of Psychoanalytic  Organizations: 2006.
  

Oken D. Multiaxial  diagnosis in the psychosomatic model of disease.

The Emperor’s  New Drugs: Exploding the Anti-Depressant Myth.

The Truth About the Drug  Companies: How They Deceive Us and What To Do About It. 

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The mental health professions are currently awaiting the American Psychiatric Association’s newest version of the Diagnostic and Statistical Manual. The need for a fifth revision underscores the lack of satisfaction within the professions with our diagnostic schema

Robert E. Kay, MD

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