Why Psychiatry Needs to Scrap the DSM System: An Immodest Proposal“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”
~ Sir William Osler (Canadian Physician, 1849-1919)

Most psychiatrists, and many patients, sense that psychiatry is in trouble these days. The reasons are complex, but boil down to a crisis of confidence: many in the general public — if they ever had faith in psychiatry — have begun to lose it.

Many psychiatrists who, like me, began their careers with hopeful idealism are now expressing pessimism or cynicism. Here, too, the reasons are complex, and have much to do with the sense that psychiatry has drifted away from its core values and central mission: the relief of human suffering and incapacity. Of course, the corrosive influence of “Big Pharma” and the gradual decline in the use of psychotherapy have contributed to this down-beat attitude.

And the highly-publicized dust-up over revision of psychiatry’s diagnostic classification — the DSM-5 (what the media love to call, “Psychiatry’s Bible”) — has certainly not filled psychiatrists with joy.

36 Comments to
Why Psychiatry Needs to Scrap the DSM System: An Immodest Proposal

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  1. What seems to me would be most helpful would be a simple scale of perhaps 5 levels or so.

    Start with
    1) Able to care for self and handle responsibilites.

    And degrading to
    5) Batshit Crazy. Needs full time care.

    But that makes too much sense for ‘big pharma’ to adopt it.

    • Interesting idea, Ruby, but your scale seems too “open to interpretation” to me. How well-off do you have to be to score a 1-someone who is never late to meetings, is president of the PTA, never fights with her spouse, pays the bills on time, and bakes brownies for new families moving in to the neighborhood while working a full-time job? Or would it be okay if she was late for a meeting now and then, and sometimes burnt the brownies?

      Also, by defining well-being by ability to function you ignore people who are high-functioning, but suffering. I was seriously depressed last semester, but I still always managed to get out of bed, shower, get dressed, and usually go to most of my classes. I nearly killed myself more than once, but I was functional. Where would I fit?

      • In August I join a conversation conducted in January 2012. I have just come across Ronald Pies’ post about why psychiatry needs to scrap the DSM and the subsequent comments. In his various replies Dr.Pies makes it clear that he does not propose scrapping DSM. We have nothing better to replace it. The atheoretical approach does not try to indicate the cause of the illness, but a diagnosis that does not indicate the cause of the problem has no practical utility. Would we stay with a mechanic who cannot ever pick what stops our car? We are lucky that some diagnoses such as bipolar disorder and schizophrenia seem near the mark of a specific genetic problem. They have opened the way to successful treatments. Psychiatry has provided a real service thanks to the serendipity of past geniuses such as Kraepelin. The whole ragbag of neuroses seem near the mark of another genetic problem. In time we will get there. For now we should understand the inevitable failure of descriptive diagnosis and the atheoretical method.

    • There are scales like that in existence based on the GAF, but they aren’t used all the much because they don’t provide enough information.

  2. I really like what you have proposed,Dr.Pies. What needs to be done to “make it happen”? I am only a college student, but I’d love to help in any way I could. I am a pre-med student who hopes to ultimately be a psychiatrist, and I have bipolar II disorder.

  3. I agree with your premise, but the solution creates a new problem: it takes away a quick and simple common language among professionals. I like the prototype idea, but we still need a fast name that I can say to you in a meeting and have you know what I’m talking about in 5 seconds, otherwise there will be mass confusion among what we are doing, which is why the DSM was created in the first place. I like how the DSM-5 is moving toward a spectrum, but I’d rather see things turn into “Anxiety Disorder Level 3″ or “Mood Disorder Level 2″, “Thought Disorder Level 2, primary feature paranoia”. Something like that lets us be general enough without taking away the easy language.

  4. Greetings to Psychcentral readers, and thanks to Dr. Grohol for hosting my essay! As per my usual practice, I am happy to respond to any fully-signed, collegial question or comment that furthers the discussion. I look forward to hearing from both mental health professionals and other readers with a stake in the outcome of the critical debate over the DSM system.

    Best regards,
    Ron Pies MD

  5. I wonder… isn’t all of clinical practice — whether medicine or mental health practice — as much an art as it is a science?

    And if that’s the case, isn’t it likely that no classification system, no matter how well-devised or thought-through, is going to capture the unique complexities of the human experience? An experience where no two people’s “depression” looks or feels or acts exactly the same?

    I fear we risk chasing an unachievable dream here, simply because we see the obvious problems and deficits in the current system. A system that despite some of its faults, I would argue, works well enough as a broad, generalized classification system.

    the DSM framework does very little to enlighten the clinician regarding the “inner world” of the suffering patient.

    I would argue that since there are hundreds of psychological theories of what that “inner world” means, and how you can model it, it gets really untenable quite quickly to try and create a singular system that takes into account these hundreds of divergent views and theories.

    It’s my understanding that that was one of the modern DSM’s original intents — not to offer theories about causes or get into goals for treatment. But instead to simply to offer an atheoretical perspective of classification which tries to observe the world through an objective and scientific lens, and put disorders into a system that helps to enlighten our overall understanding of them (and in a more gross, generalized manner, the individual).

    An analogy would be a biologists view of nature. They classify plants, and those classifications help them understand plants, but it doesn’t help them appreciate and understand a specific, individual plant under their care.

    Classification systems do not take away our empathy or understanding of individual people, if we don’t let them (and I don’t know of any clinicians who do). Just as a biologist’s classification doesn’t take away from their understanding of an individual plant and the unique attributes it may have (or its unique needs if it’s unhealthy or dying).

    So while I agree the DSM is not necessarily the best system we have, it is a good system nonetheless and one that has shown a respectable history of working pretty well. Not ideally, of course, but pretty well.

    John Grohol, PsyD
    Psych Central.com

  6. I hear the concern of Dr. Pies but I am not sure there is a direct correlation between the diagnosis and treatment. I feel that Dr. Pies voices a concern many of us have when he states, “Of course, the corrosive influence of “Big Pharma” and the gradual decline in the use of psychotherapy have contributed to this down-beat attitude.” My concern is how did that happen and how to reverse it. My field covers long term care where we treat many patients with a variety of forms of mental illness. Our focus is more individual and group therapies and drugs when absolutely required and only in as low a dosage and for as short a time as needed. That is vague but even so you can see the focus is more in terms of helping the patient repair their life (and mind) to the extent that they can and although medications can help and are sometimes required, they frequently slow down or halt the recuperative process. So I do not think the DSM is necessarily the most important issue but rather what may be considered best practices for treatment for a diagnosis. It seems to me that what may be needed is out of the medical sphere in that insurance companies can drive treatment options. As in many arenas when money is a driving issue with short term goals, long term results suffer greatly as do our patients. I am sad to say but this may be a political problem. If so it may take much more than discussion among those in the profession to change. If may take a group effort by we professionals to lobby congress. But the DSM does need improving regardless.

  7. i don’t envy those individuals who are called to the task of planning/creating/editing the dsm iv. one of my greatest concerns is that, while there may be inter-rater reliability, so much else is missing with our current approach. it seems like professionals with whom i have worked DON’T realize that that the diagnosis really offers so little relevant information. once they hear my diagnoses, it seems as though they think they know something about me. they DON’T. there is no room for STRENGTHS with the system we have now, either.

    for example– on paper, i look the same now (with an active, happy, life) as i did six months ago when i was an inpatient in the state mental hospital, unable to imagine NOT killing myself in the near future. that similarity is in diagnosis alone– not in my quality of life, not in my ability to function…. but my diagnosis stays the same….

  8. I don’t think that the crisis in psychiatry is precipitated by the diagnostic manual. Most practicing clinical psychiatrists only use a portion of it anyway and when they do it is in a pattern matching procedure like the one that you proposed.

    The main problem with any diagnostic manual is that organized psychiatry has not been specific enough on who is qualified to use it. Even diagnostic categories with the greatest reliability and validity require a person who has been trained in psychopathology and I am not convinced that the people who purchase it or comment on it have sufficient training. Spitzer criteria have literally given the illusion that anyone can make a “diagnosis” and nothing is further form the truth.

    The real crisis in faith in psychiatry has come from 25 year of managed care and organized psychiatry’s lack of ability to respond to the clear discrimination against managed care companies denying effective treatments to our patients and the necessary resources to psychiatrists.

    George Dawson, MD , DFAPA

    • “The real crisis in faith in psychiatry has come from 25 year of managed care and organized psychiatry’s lack of ability to respond to the clear discrimination against managed care companies denying effective treatments to our patients and the necessary resources to psychiatrists.”

      Hit it right on the head for me. The APA lost me as a member back in the mid 1990s when the election for President basically boiled down to whether psychiatry was going to tolerate the intrusions and directions that Managed Care was fostering and scheming further, or not; 48% of the membership voted essentially “fine, let’s just do it and figure out a way to continue to thrive financially first”.

      I have had colleagues tell me that kind of commentary is just harsh and dismissive of alleged real efforts to be helpful to our patients. But, when the profession allowed itself to be so pigeon holed into just doing 15 minute med checks and only be able to submit billing for certain diagnoses, where was the outrage and defiance to stand up, advocate for the people, and by the way, challenge other professions that alleged they could take on psychiatric responsibilities when the evidence and patient care outcomes really showed otherwise?

      That silence really has figuratively and literally been deafening and deadly. And now, I read about the DSM5 being just another tool for others outside the profession to direct what little left psychiatry has as legitimacy and respect. I don’t really care if I am the only one with intestinal fortitude to offer this: the good ol boy network that is both the APA and academic psychiatry for too long is selling out the rest of the field so they can all retire to just slap each other on the backs to say basically, “well guys, we rode it out and still made out fairly comfortable”.

      Hey, if you, as in fellow colleagues, disagree and have legitimate examples to show otherwise, prove me wrong. I’ve been waiting ten or more years with this challenge to be shown otherwise. Do we as psychiatrists have another 5 or more to salvage what little left is there to restore some semblance of honor, integrity, and advocacy as professionals?

      Joel Hassman, MD
      Board Certified Psychiatrist since 1997

  9. I agree with Dr. Dawson in part. As in many other aspects of medicine, to my mind treatment options should not be limited by the funding agent, i.e. the insurance or managed care company.

    I also see lizzy’s point that the DSM is focused on diagnosing psychopathology without respect to the patient’s strengths, which could point the way to more effective treatment. Thanks lizzy!

  10. I agree with Dr. Grohol that there is probably no perfect diagnostic world out there to be had. There are plenty of reservations we will always need to keep in mind when making categorical diagnostic decisions (regardless of whether we’ve conceptualized them dimensionally). Certainly with DSM-IV’s criteria based approach we have a lot of problems- but with Dr. Pie’s template matching approach we may also potentially end up having clinicians subjectively “decide” how much the person may or may not be similar to that narrative (a narrative which implicitly contains “criteria,” just not in checklist form). You could just as easily have something like the DSM-IV criteria without a specific, required number that must be met and have essentially the same thing as narrative proposals.

    What I like and what I think is important is that we’re looking to address issues. When all we do is complain about a vast Big Pharma conspiracy we aren’t really improving much. The DSM-IV disorders shouldn’t be viewed as necessarily and completely “real” and nor should the DSM-5. I like Dr. Grohol’s indication that they can potentially be useful, however. Suggesting we should get rid of diagnoses altogether could be a slippery slope to suggesting psychologists and others aren’t even health care professionals. Anand’s comment is my favorite “So I do not think the DSM is necessarily the most important issue but rather what may be considered best practices for treatment for a diagnosis.” The DSM-5 debate is important but perhaps a distraction from a more important debate about what we actually do with these presenting problems.

  11. The rational, thoughtful approach to psychiatric diagnosis; the problems of reimbursement by third party carriers; the goals of the pharmaceutical industry; the criticisms of the neo-Szasz-ians; and the interests of the neuroscience researchers are all very different things. Trying to serve all of those gods with the DSM-anything is a fruitless exercise. So step one is eliminating the other considerations. Thanks for a thought provoking post…

  12. “Classification systems do not take away our empathy or understanding of individual people, if we don’t let them (and I don’t know of any clinicians who do).”

    But haven’t you [Dr John] consistently argued against the concept of ‘internet addiction’ on the basis that it doesn’t aid our understanding of the phenomena of people using the internet to excess; and doesn’t this very point tie in with the point made by Ron that an excessive focus on symptoms does have the potential to obscure a clinican’s understanding of the patient’s inner experiences?

    It seems to me that the two points are very much related.

    I agree with Dr John that clinicians may have the ability to not allow classification systems to take away their understanding of individual people, but is this everyone’s experience? I’m pretty sure that more than a few patients would report that they felt that their clinician was seeing them as a condition and failing to see them as a person. Furthermore – and I think that this really is the point – shouldn’t the systems/ideas/diagnoses cateogories which clinicians use ideally reflect the reality that their is a person beyond the condition, and actually promote that understanding?

    Whilst I’m sure that DMS has plenty to commend it, and Ron may be over-stating his point a bit, I enthusiastically agree with Ron’s final statement that “psychiatrists and other mental health professionals owe it to themselves and their patients to think more boldly — and more philosophically — about their diagnostic system.”

    Adam Waterhouse
    Southampton, England

    • Adam wrote:

      But haven’t you [Dr John] consistently argued against the concept of ‘internet addiction’ on the basis that it doesn’t aid our understanding of the phenomena of people using the internet to excess;

      I haven’t intentionally argued that point. My gripe with “Internet addiction” is primarily a scientific one — the research in this area is often downright horrible, poorly done, and reliant on unscientific measures. And the fact that we’re demonizing the technology, when there’s no logical reason to do so.

      Here’s the reality of things (in the U.S. anyways). Most antidepressants here aren’t prescribed by a psychiatrist or trained mental health professional — they’re prescribed by general practice docs and family physicians. No matter what system you use or devise, these folks, although well-intentioned, will rarely follow the criteria as carefully as a mental health professional.

      I think if you want to look at the problem of “over diagnosis,” you need look no further than this issue. And until we’ve figured out a way to either (a) get GPs to stop diagnosing mental disorders and/or (b) get people to go to actual mental health professionals, diagnosis of disorders will remain the patchwork quilt it’s always been.

      John

      • Dr. Grohol has a good point when he says, “And until we’ve figured out a way to either (a) get GPs to stop diagnosing mental disorders and/or (b) get people to go to actual mental health professionals, diagnosis of disorders will remain the patchwork quilt it’s always been.” I wonder what difficulty GPs have in referring a patient to a mental health professional? Are the insurance companies and managed care organizations making it easier or harder for GPs to make such referrals? Will insurance companies and managed care organizations cover the cost if a patient goes directly to a mental health professional? It may be that the GPs feel they are between a rock and a hard place if their patient’s insurer will not cover mental health or makes it oppressively difficult for the GP. Yes, GPs do not have the proper training or experience to design a treatment plan for a patient with mental illness. However, there may be no other viable health practitioner that the patient can afford to go to. In the U.S. you get the health care you can afford, not that you need. Until that changes…. I can only voice my concern again that many medical problems sadly to not have medical solutions. I only wonder when those with the most education and medical authority will stand up and demand the obvious; health care in this country based on need not greed.

      • Pretty much just hit it on the head right there.

  13. It’s not just Big Pharma that’s got us where we are with the DSM. Healthcare and what they will and won’t cover, along with what the schools will and won’t provide services for for children, are another thing entirely. Health insurance plans hold on tight to every last penny, and if it’s not “in the DSM,” it’s now the family’s job to either cover expenses out of pocket, attempt to provide services on their own despite lack of training, or suffer through with symptoms and likely misdiagnoses and very possibly with completely inappropriate treatments.

    Our family is ridiculously fortunate that we were able to cover *some* of the OT needed to help a child cope with Sensory Processing Disorder that was interfering with her inability to handle daily life in a school setting, and that I had the intelligence and understanding and persistence to discount an incorrect ADD diagnosis (I was literally pushed out the door with a Ritalin prescription by a psychiatrist who was sure that it would help a 5YO who was constantly overstimulated and going through extreme rages) and apply some DIY OT to the issue, but as a teacher I see countless kids daily who would benefit from OT but are instead on medications for ADD and then other meds for the effects of the stimulants – partly due to misdiagnosis or inappropriate treatment in some cases, but also because their disorder “doesn’t exist” in the first place. And if it doesn’t exist, nobody is obliged to treat it. :-(

    My daughter is doing well now: her symptoms are better after lots of OT (we had to get a diagnosis of something else entirely to get her the OT, but we got it), managed partly with diet and lifestyle. Her therapist told us point blank that he didn’t think that SPD would be in the next DSM, or in any, and that he wasn’t convinced it should be there anyway. And as long as that mindset exists among providers, especially those beholden to health plans (We sadly are under an HMO umbrella whose motto is “Thrive.” Ha! :-(), and as long as health plans are more interested in the almighty dollar than in total patient health, I really do think we’re stuck here. (I would very much like to be wrong about this, though. :-))

  14. I think that one of the difficulties of this discussion is that there are so many different stand-points from which it is possible to approach it from. I think I agree with Ron’s general points, but I can also see some very good reasons why practitioner’s or patients might want to defend the diagnostic system as it currently stands – because it offers the hope of parity with physical health difficulties. What I think patients are really wary of, and understandably so, is any suggestion that their problems are ‘just psychological’ or ‘just subjective’ and therefore not deserving of sympathy or state-funded treatment or benefits.

    What I would say is that these pragmatic considerations about the reality of front-line practice are somewhat different from the question of how we can best understand mental illness. The question of how we can best advocate for the interests of people with mental health problems is something else again. It is a complex and multi-faceted debate, and I think that these different strands need to be separated out.

  15. I agreed with Dr John’s rejection of ‘internet addiction’ on the basis that I don’t personally believe that it provides any insight into the reality of the experience of someone using the internet to excess, and appears to confuse cause and effect (i.e. the fact that a person is using the internet excessively is quite likely the result of other problems in their life). I agree with Ron’s rejection of mental health diagnoses based upon symptoms alone for the same reason. At least we shouldn’t take such diagnoses too ‘literally’.

    This is a subtle point that can easily be misunderstood (and is probably not expressed as well as I might hope) but I will try to explain…. I often read people on PC make remarks such as “I’m so devasted to learn that I’ve got bi-polar disorder/ major depressive disorder/ border-line personality disorder” etc. Without wishing appear insensitive to the feelings of such people, I have to admit that I always find that such comments sound odd to me, and seem to be based upon an over-medicalised view of mental-health problems. If I go to my doctor feeling very run down and have some tests done, it would be perfectly rational for me to feel relatively relieved to find out that I had an iron deficiency (that could be easily dealt with by a change in diet or iron tablets) or alternatively quite devastated to learn that I had cancer (no explanation required). The two alternative diagnoses would point to two very different aietiologies for my symptoms, which would indicate two very different prognoses. If on the other hand I go to the doctor feeling a bit unhappy would it really make any sense for me to feel elated to be told that I was “not really depressed as such” or devasted to learn that I had Major Depressive Disorder? Surely with something like depression the problems is the experience itself, and the diagnostic category is just a label for the experiene itself and does not indicate a clear aietiology and prognosis in the way that physical disease diagnoses do?

    I would like to quote Carl Jung from Memories, Dreams, Reflections describing his experience of reading a textbook on Psychiatry and how and why this influenced the course of the whole of the rest of his professional life:

    Beginning with the preface, I read: “It is probably due to the peculiarity of the subject and its incomplete state of development that psychiatric textbooks are stamped with a more or less subjective character.”…. My heart suddenly began to pound. I had to stand up and draw a deep breath. My excitement was intense, for it had become clear to me, in a flash of illumination, that for me the only possible goal was psychiatry. Here alone the two currents of my interest could flow together and in a united stream dig their own bed. Here was the empirical field common to biological and spiritual facts, which I had everywhere sought and nowhere found. Here at last was the collision of nature and spirit became a reality.”

    Jung definitely had a bias for the subjective side of life, but also had a profound empathy for people with all manner of mental illnesses. Note also the apologetic tone of the author of the textbook regarding the subjective nature of psychiatry contrasted with Jung’s extreme enthusiasm of that very point! We bring our own personalities and preferences to this type of discussion and this is a point to be acknowledged rather than overlooked.

  16. Many thanks to all for the thoughtful and thought-provoking responses! I promise a substantive response soon. –Best regards, Ron Pies MD

  17. I agree with Dr. Pies viewpoint and think that although the DSM has been an admirable attempt to “scientize” psychiatry, the original phenomenology of Jaspers was more realistic. It is time to throw out the whole concept of “mental” disease and recognize simply diseases of human beings. Descartes hangs over us like a dark shadow and we cannot seem to rid ourselves of his influence. Psychiatrists should be specialist in human behavioural disorders, not “mental” disorders. Schizophrenia has more behavioural aspects than diabetes but they both seem to be genetic or metabolic disorders. The world of philosophy has been escaping Descartes since the 1940s, it is time medicine did it as well!

  18. OSLER’s dictum is the ESSENTIAL clinical guide. IMHO most clinicians use intuition in applying the DSM. medication is a cover-all when the presentation does not fit DSM closely, N of 1.

    Unfortunately psychiatry training no longer pays enough homage to the person, so, regardless of which psychotherapeutic paradigm one is attracted to, it no longer pays to delve into their lives and functioning capacity, past or present.

    the problem with the new DSM is trying to break up observable phenomena which are in the eye of the beholder, into even more categories which are not correlated with brain abnormalites. it is pointless trying to count the number of up or down mood swings, as if this will determine the difference between borderline and bipolar.

    on the other hand, distinguishing child problems such as sensory processory, auditory processing both of which might produce concentration problems, from ADD/ADDH, ASP, might be useful. Then non-medical-behavioural, educational,approaches might be useful if accepted across educational domains where one size does not fit all.

  19. Psychiatry should be integrated with psychology. Bring back the psychoanalyts. Or psychiatrists should at least study psychology before they become medical doctors.

  20. I would like to thank all who commented on my blog, many of whom made valuable points and observations. I regret that I can’t respond personally to each of you! Several readers raised quite legitimate concerns regarding my proposal, while a few may have been laboring under a slight misunderstanding of my position. And so, I would now like to clarify my basic argument; summarize areas of agreement and disagreement with various readers; and then present some further arguments in favor of the “narrative-phenomenological” method of diagnosis I am advocating.

    First of all, I am not arguing for a complete elimination of the criterion-based, categorical approach used in the DSM-III and IV; rather, I would retain an updated version of these criteria as an “appendix” to the new, clinically-oriented manual. Second, my approach does not consist of simple “narrative” accounts of psychiatric illness; rather, it is a “narrative-phenomenological” approach, in which the prototypical patient’s “inner world” is explicated in much richer detail than anything in the DSMs. (Readers who want to delve will be rewarded by reading Dr. Silvano Arieti’s magisterial classic, Interpretation of Schizophrenia, in which Arieti reveals the subjective life of the patient in ways that the DSM never remotely approaches).

    In this respect, I am attempting something similar to what the psychoanalysts undertook, in their “PDM” (Psychodynamic Diagnostic Manual) in which they focus on the patient’s internal experiences as well as surface behaviors [see http://www.pdm1.org/. I am not eliminating “categories”, or familiar, clinical short-hand terms, such as schizophrenia, major depression, or bipolar disorder. Rather, I am arguing that there may be better ways of recognizing and understanding these conditions than now available with the DSM system.

    My system is not really “cause-based”, since we lack sufficient understanding of most psychiatric disorders to specify “causes”. I believe that what I am suggesting is actually fairly similar to the approach used in the International Classification of Disease (ICD-10). The ICD uses “categories”, but avoids an “either you have the condition, or you don’t” approach. Rather, ICD guidelines reflect varying degrees of “confidence” in a diagnosis, and are worded “so that a degree of flexibility is retained for diagnostic decisions in clinical work.” For example, in ICD-10, statements about the duration of symptoms are intended as general guidelines, rather than strict requirements. [see http://apps.who.int/classifications/icd10/browse/2010/en#/F30-F39

    I agree with Dr. Dawson that the DSM per se is not the "main cause" of the crisis now facing psychiatry. In a paper now in press in Psychiatric Times, I outline at least four other major problems that do underlie the crisis; e.g., psychiatry’s inability, thus far, to develop robustly effective, well-tolerated treatments for several major disorders, such as schizophrenia, autism, and most of the severe personality disorders; psychiatry’s increasingly and inappropriately close ties with the pharmaceutical industry in recent decades; the decline, over the past decade, in the use of psychotherapy among U.S. psychiatrists, and the attendant public perception that psychiatrists “no longer listen” to their patients; and finally, a lack of understanding among the general public of the benefits of psychiatric treatments, and not simply the risks. This last point reflects insufficient educational efforts and “outreach” on the part of the profession, in my view. I offer some possible responses (if not solutions) to these problems, but that is beyond the scope of the present article. (The article will appear in the February and March issues of Psychiatric Times). Similarly, I agree with Dr. Anand Holtham-Keathley that the DSM is not necessarily “the most important issue”; and that ultimately, the “best practices for treatment for a diagnosis” are what really matters. However, correct treatment requires, in the first place, correct diagnosis; and diagnosis requires understanding of what the patient is actually experiencing. I do not believe the present symptom-and-sign based (DSM) framework provides us with the best means for achieving such understanding.

    I agree with Dr. Grohol that diagnosis (literally,“knowing the difference between”) is often as much an art as a science; and that “no classification system, no matter how well-devised or thought-through, is going to capture the unique complexities of the human experience.” True enough! I also agree with Dr. Grohol that “Classification systems do not take away our empathy or understanding of individual people, if we don’t let them”. However, our methods of diagnosis may, to greater or lesser degrees, allow us to be in touch with our patient’s internal subjective experience--without which empathy becomes much more difficult.

    Alas, I am not as sanguine about the present DSM system as my friend John Grohol. Indeed, to suggest that the present system works “well enough” requires that we have some measurable parameters for working “well”. I am not convinced we have that kind of empirical evidence for the DSM-III or IV, though I acknowledge that these manuals have fostered greater inter-rater reliability among researchers. Have they really reduced the net amount of psychologically- based misery in the world, compared, say, with the old, description-based DSM-II (1968)? Here, too, I am not convinced. And reducing such misery is the main reason many of us went into this field!

    Moreover, if working “well enough” includes acceptance among clinicians, there are good reasons to question how well the DSM is working. Thus, there is evidence that most psychiatrists do not prefer a criterion-based, categorical approach to a more clinically descriptive system. For example, in the WPA-WHO Global Survey, over two-thirds of the participants (practicing psychiatrists) maintained that a diagnostic system based on clinical descriptions is more clinically useful than one based on operational criteria. The proportion of DSM-IV users endorsing this position was slightly higher than that of ICD-10 users. (see Maj M, World Psychiatry. 2011 June; 10(2): 81–82).

    Furthermore, there is good evidence that many psychiatrists--and an even greater percentage of primary care doctors-- are not making use of the DSM criteria, at least with regard to diagnosing major depressive disorder (MDD). For example, Zimmerman & Galione (2010) showed that nearly 25 percent of the psychiatrists indicated that they used the DSM-IV MDD criteria to diagnose depression less than half of the time. Even more striking, over two-thirds of the non-psychiatrist physicians indicated that they used the DSM-IV MDD criteria less than half of the time, when diagnosing MDD. The authors concluded that “While the symptom criteria for diagnosing MDD have not been changed much over the last 30 years, psychiatrists, especially older psychiatrists, apparently have not uniformly embraced their use and non-psychiatrist physicians seem to have rejected the formal application of the criteria.” (Zimmerman & Galione, J Clin Psychiatry. 2010 Mar;71(3):235-8. Epub 2010 Jan 26). Thus, this evidence supports Dr. Dawson’s statement that “Most practicing clinical psychiatrists only use a portion of [the DSM] anyway and when they do it is in a pattern matching procedure like the one that [Dr. Pies] proposed.”

    I think it is also debatable as to whether the DSM system is truly “atheoretical.” Arguably, it is steeped in a theory of positivist-empirical philosophy, which holds that knowledge is best gained by direct observation and measurement [see ref. 1]. One can endorse this view, but it is still part of a philosophical theory of knowledge. So, too, is the notion (implicit in the DSMs) that we can make valid inferences about inner (“mental”) states, based on primarily external (observational) criteria. Maybe so, but again, this is part of an epistemological theory. Moreover, some of the DSM diagnoses, such as conversion disorder and PTSD, are not truly atheoretical, in that they posit a sequence of causal events leading up to and triggering the clinical syndrome. Many philosophers of science would indeed suggest that no diagnostic system is truly “atheoretical” and, of course, that includes the one I am proposing.

    Finally, I agree with Dr. Finnerty that there are risks in a “template” or “prototype”based diagnostic system. Thus, Dr. Finnerty notes that the “template matching approach” may wind up “…having clinicians subjectively “decide” how much the person may or may not be similar to that narrative…” True: but clinicians using the DSM also must decide ‘subjectively’ if a patient meets specific DSM criteria, such as degree of impairment in social or vocational function, or “clinically significant distress.” It is not clear that looking at a “gestalt” template or prototype will require more “subjectivity” than that required to address the numerous individual components and exclusion clauses of a DSM-IV-type diagnosis. Nevertheless, a recent opinion piece by Maj echoes some of Dr. Finnerty’s concerns; e.g., “Being influenced by those templates, [clinicians] may selectively catch or recall the various features of a prototype, or may read in a prototype description elements which are not actually there.” (Maj M, Psychiatric diagnosis: pros and cons of prototypes vs. operational criteria. World Psychiatry. 2011 June; 10(2): 81–82.

    In short, no diagnostic system will solve all the problems clinicians and researchers face, or fit all the needs of both researchers and clinicians. On balance, I believe that a narrative-phenomenological (prototype) approach will be better-accepted by most clinicians than the present DSM “bean counting” system; and that narrative prototypes also afford a deeper and more empathic understanding of our patients. As Einstein once observed, “Not everything that counts can be counted; and not everything that can be counted counts.”

    Ron Pies MD

    P.S. A special note of thanks to Dr. John Dale, for his philosophical perspective on these issues.

    1. Hanfling O: Logical Positivism. In: Philosophy of science, logic, and mathematics in the twentieth century, by Stuart Shanker. Volume 9 of the Routledge History of Philosophy, New York, Routledge, 1996. pp. 193-213

  21. Dr. Pies—–wow….what terrific work you are doing…will you be having a meeting of like minds on any issue involving changes that are needed with psychology, psychiatry, and neurology?
    thanks from harry2

  22. This is quite a thoughtful and thought-provoking discussion. As an outsider, I can see that there are significant problems with mental health diagnosis. It seems to me that some of these things wouldn’t be as much of an issue if there weren’t as many patients having poor outcomes to treatment.

    While those of you in the mental health professions sort out how best to serve your patients, please know that your work is extremely meaningful. Although I haven’t always said so, I am profoundly grateful to every person who lent their expertise to helping me through depression and anxiety. Some attempts were more successful than others, but I appreciate them all for caring. I don’t think that gets said enough.

  23. My book, They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal, is based on what I learned as a psychologist who was for awhile (until I resigned in horror when I saw how the DSM people actually work) on two DSM-IV committees. I documented there the unscientific, highly political nature of psychiatric diagnosis, as well as the wide array of kinds of harm that can result from psych dx. I also documented that assigning these diagnoses does not improve treatment or prognosis. In 1985, with DSM-III-R in preparation, when we heard about some particularly appalling proposals for new categories, I started a petition in protest that drew more than six million people, including major organizations. This failed to slow the DSM juggernaut, as did protests about DSM-IV and the upcoming one.

    Alarmed by the massive numbers of people who have been seriously harmed over the decades because of psychiatric diagnosis, which is not scientifically grounded, rarely helps, and often has negative consequences, and knowing that the next edition of DSM will likely be sent to press this coming May at the American Psychiatric Association convention, we have decided it is time to stop asking the DSM editors to listen and instead to take actions.

    We are planning a series of actions of various kinds, and soon we will have a website with lists of our individual members and their bios and our organization members and their mission statements.

    We’d be so grateful for your assistance in spreading the word about these first two actions of our PLAN T Alliance (Psychiatric Labeling Action Network for Truth), and if you would like to join the Alliance and have no connection to Scientology or their CCHR, please let me know that in an email and send me your bio or your organization’s mission statement.

    Boycott the DSM
    http://www.change.org/petitions/boycott-the-dsm

    and

    Call for Congressional Hearings about Psychiatric Diagnosis
    http://www.change.org/petitions/everyone-who-cares-about-the-harm-done-by-psychiatric-diagnosis-endorse-the-call-for-congressional-hearings-about-psychiatric-diagnosis

    Thank you,

    Paula J. Caplan, Ph.D. (for the PLAN T Alliance)
    Fellow, Women and Public Policy Program, Harvard Kennedy School
    and
    Associate, DuBois Institute, Harvard University

  24. Many people are only too grateful for their psychiatric diagnosis and the credibility and legitimacy that this gives for difficulties they experience. They want compassionate recognition of their suffering and difficulties AND empathic understanding of their strengths and potentials. Mental health diagnoses can and often do promote compassion for people who receive the. And we have to be realistic about what it is that mental health diagnoses have replaced, which is an attitude of regarding people with mental health difficulties as morally deviant. In some cases mental health diagnoses have meant the difference between a person being incarcerated (or possibly even executed) or receiving treatment.

    My beliefs about mental health diagnoses are that whilst they can and do promote a compassionate recognition of the sufferings of people with mental health problems they may not do enough to promote an empathic recognition of their strengths and potentials…. but to present mental health diagnoses as some great evil which requires a movement to crush…. I just find this an over-the-top reaction and don’t think that it will help at all.

  25. Anand Holtham-Keathley, thank you for your posts.

    It’s individual doctors who apply arbitrary diagnosis and medication, with poor outcomes and injury to patients. The system doesn’t make them do it. When it comes to psychiatry, bad medicine is being practiced everywhere.

    Non-psychiatrists are terrible at diagnosis, psychiatrists are not much better, and all are simply throwing prescriptions for psychiatric drugs at their patients.

    Whatever classification system doctors are using incompetently is almost irrelevant. Control by managed care is a red herring.

    The influence of pharma, though — that’s another story. Who is it persuading doctors of all kinds to reflexively vend psychiatric drugs for whatever ails you?

    And doctors, supposed to be an intellectual elite, why don’t they see through these machinations?

    Why hasn’t psychiatry taken the lead in critiquing the overprescription of medications? Instead, it resists every effort to make patient safety a priority.

    Dr. Pies himself has claimed that criticism of psychiatry by non-psychiatrists is a conspiracy of hysterical no-nothings. He wants to keep criticism within the family, but psychiatry is a family determined to keep its dysfunction secret.

    Over and over, outcomes research shows questionable benefit of psychiatric drugs but psychiatry, over-identified with the pharmaceutical model, keeps on defending their unrestricted prescription.

    The APA is a trade organization encouraging nothing but the purveying of drugs. Why do psychiatrists continue to pay their dues?

    Yes, its publishing a catalog of diagnoses provided by drug companies to match their drugs is bad for psychiatry and bad for patients, but that’s only a symptom of what’s wrong with the entire field.

    There is no penalty for bad outcomes in psychiatric treatment. A system needs to be set in place to hold individual doctors responsible. If that strikes fear in your heart, maybe you need to prescribe more conservatively.

  26. Many thanks to those of you who have written in since my last (long!) comment. While my standing policy is to respond only to fully-signed communications, I do appreciate the thoughtful comments from all of you.

    I would like to say some more on the issue of “diagnosis” and “labeling”. Of course, there are always risks in applying a diagnosis to a patient, and not just in psychiatry. A medical term or “label” like “obesity” can certainly cause hurt feelings or diminished self-esteem, if it is presented in a callous or casual way; yet the condition being described can do great harm if it is not recognized and treated. This is no less true of bipolar disorder or schizophrenia than of coronary artery disease–all “labels” that may be applied to seriously ill individuals.

    The term “diagnosis” literally means, “knowing the difference between.” There is simply no way to
    provide ethical and effective health care unless, indeed, we can describe “the differences between” one
    condition and another. Just as internists need to distinguish between pneumonia from asthma,
    psychiatrists need to distinguish between, say, post-traumatic stress disorder and schizophrenia.
    Otherwise, the patient’s treatment will suffer, and
    so will the patient.

    So, in my view, it is not helpful to imagine any branch of medicine doing away with diagnosis–and this inevitably means using descriptive terms, such as “bipolar disorder” or “major depressive disorder.”

    To be sure: we should resist thinking of diagnostic terms as hard-and-fast “entities”,in the way we think of rocks, trees, and tables. Our diagnostic terms are
    conceptual tools, not “things” in the strict sense. Yet I believe these tools, when properly used,
    do point to characteristic types of human suffering and incapacity. Harm that comes from the
    abuse of a diagnosis–for example, when patients are denied certain benefits or privileges, as a
    result of prejudice or discrimination–does not invalidate the diagnostic process, or render it
    inherently harmful. Rather, such abuse points to certain unjust legislative and administrative
    practices that need to be corrected.

    For example, if someone receives a diagnosis of “epilepsy”, and is then unfairly denied driving privileges despite being perfectly stable, we
    don’t automatically conclude that “epilepsy” should be eliminated as a diagnosis, or that it is
    merely a pejorative label; rather, we work to make the rules concerning driving privileges more equitable.

    By the same token, I do not wish my criticism of the DSM system to be read as an attack on the people
    involved in the DSM process. I believe that, in most cases, these individuals are undertaking a
    difficult task with good intentions, and that they sincerely desire to help those with psychiatric
    illness–even if, as I believe, the DSM approach is misguided. Furthermore, I think we need to be
    very careful in criticizing methods and diagnostic systems as “unscientific”. That term requires
    a good deal of discussion. What constitutes “science” or “the scientific method” has been the subject of controversy and debate for decades, among scientists and philosophers of science.[For those who want to delve into the debate, I recommend the excellent book, Philosophy of Science: A Very Short Introduction, by Samir Okasha. You can also find
    detailed philosophical discussion of the DSM controversy
    at: http://www.peh-med.com/content/7/1/3 and at http://philpapers.org/archive/PIETAC-2.1.pdf.

    Some critics of psychiatric diagnosis argue that it is “unscientific” because it is not tied directly to biochemical abnormalities (which is true); yet this is a very narrow and, in my view, wrong-headed notion of what the word “scientific” means. For many philosophers, the scientific method entails
    the use of careful and repeated observations that can be duplicated by others, with systematic
    attempts to refute and confirm one’s hypotheses through careful, controlled investigations.

    To be sure, a number of the DSM categories can be challenged on these grounds, and I’m of the view that some (not all!) DSM diagnoses, such as “Oppositional Defiant Disorder”,have been spun out of very flimsy scientific cloth. But this does not mean that psychiatry as a whole, or the diagnostic process itself, deserves condemnation; rather, it suggests that some unfounded decisions have been made, with respect to specific diagnoses.

    And so, I return to my main thesis: the DSM system doesn’t adequately serve the needs of many–perhaps most–mental health clinicians; nor does it provide an in-depth understanding of the patient’s “lived
    experience” or inner world. Of course, those issues will vary from person to person, and no
    diagnostic system can capture the nuances of a particular individual’s world view. But we can
    do better than the check-lists of the DSM. We can make our diagnostic categories more fluid,
    more flexible, and more attuned to how patients actually experience particular illnesses. And
    yes–we must avoid “labeling” in a way that demeans the patient; pretends we know more than we do; or ignores the patient’s strengths and potential to grow–or even recover!

    Most of all, our diagnostic process must bear in mind the chief aim of the healing professions: to alleviate human suffering and enhance life for those we treat.

    Ronald Pies MD

  27. Ron,

    For an example of your question about phenomenology, have a look at the comments of those who have signed the DSM-5 petition. Page 213, Signatory 10648.

    Meanwhile, great article! Thanks.

  28. Epilogue to a Dialogue 3/22/13

    I am updating this blog in light of the hundreds of responses to my recent posting in the New York Times:

    http://www.nytimes.com/2013/03/20/opinion/invitation-to-a-dialogue-psychiatric-diagnoses.html

    There is insufficient space in the Times to respond to all these readers, though I do reply to four in the Sunday edition. I would like to clarify an important point, however. My letter on the need for “diagnosis” in psychiatry was not a blanket endorsement of the DSM-5, as some readers seem to have concluded. (I had no formal involvement with the
    DSM-5′s development, though I did co-author a number of articles related to the bereavement exclusion).

    Readers of the blog above will understand that I am not a huge fan of the “categorical” approach taken by the recent DSMs. I respect the professionals who spent so much time and effort developing the DSM-5, but I also have serious concerns about some of the decisions that were made; for example, as Dr. Allen Frances has noted, the “Somatic Symptom Disorder” category seems likely to be overly-inclusive, and perhaps to discourage a full medical work-up for patients reporting bodily symptoms.

    As I indicate in the blog above and in the Times letter, “diagnosis” means “knowing the difference
    between” one condition and another. It is necessary,
    but not sufficient, for a deep understanding of the
    patient’s “personhood”, and is no substitute for understanding the patient’s inner world and individuality.

    The DSM’s categorical approach makes good sense for designing research studies, but it is not the final word in diagnosis, nor was my letter to the Times meant as a paean to the DSM-5. Nonetheless, when used cautiously, and in combination with other modes of understanding the patient, the DSM-5 may be a useful, albeit rough, guide to the patient’s problems.

    Ronald Pies MD

    • Dr. Pies, for years I have been an avid reader of your works, and an admirer of how you can take complicated topics and boil them down into a concise, thoughtful analyses.

      I encourage readers to click through and read Dr. Pies succinct letter, which includes this reminder that there remains a lot of medicine that is just as subjective as psychiatry is:

      But in truth, numerous medical and neurological diagnoses, such as migraine headache, are based on the same type of data that psychiatrists use: the patient’s history, symptoms and observed behaviors. I believe that psychiatric diagnoses are castigated largely because society fears, misunderstands and often reviles mental illness.

      The DSM is not — nor has it ever been — a perfect diagnostic system. Such a system simply doesn’t exist — in psychiatry or medicine. What it is is a darned good system that has its flaws. And despite those flaws, it has allowed hundreds of thousands of clinicians and researchers communicate reliably and gain new insights into these conditions, over the past 4 decades.

      For every “solution” proposed for the DSM, I could readily cite another dozen problems that will arise with that solution — just as DSM critics like to do with the existing DSM.

      The fact remains is that the DSM-5 has been the most open and transparent update & process connected to any psychiatric diagnostic system — and I daresay any medical diagnostic system. Critics will always be in great supply of imperfect systems. But when dealing with human maladies, I doubt a “perfect” system will ever come to pass.

      Kudos to Dr. Pies. We are honored to count him among our regular contributors here at Psych Central.

  29. Dr. Grohol’s kind comments are much appreciated! I hope to follow up my NY Times letter with a much more nuanced piece, very soon. Thanks, as always, to John Grohol and Psychcentral for their encouragement over the years.

    Regards,
    Ron Pies MD

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