In May 2013 the American Psychiatric Association published the newest diagnostic tool for mental health, the DSM 5. This is the fifth major publication of what many consider to be the Bible of mental health. It is used by mental health practitioners (psychiatrist, psychologists, and counselors), courts, insurance companies, and government agencies in their diagnostic and decision making activities related to mental health. As a result of its widespread use, any changes receive increased media attention and scrutiny by professionals. It has been fifteen years since the last revision of this book and the changes made this year have not necessarily been welcomed by professionals and other interested groups. The controversy over the removal of Asperger’s as a diagnosis is one example you may have heard about and one change that has received considerable attention.
In the interest of public education I would like to offer a couple observations about the DSM 5 and how it may affect you as a consumer of mental health services.
1. Diagnosis of mental illness is a fluid process and diagnostic precision is an expectation that is too high.
Psychiatry has historically been the ignored step-child of medicine. Western scientific medicine has seen mental health diagnosis as imprecise, lacking the certainty that many medical diagnostic tests offer. Though every medical diagnostic test (MRI, blood work, or xray) has some possibility for misdiagnosis, western medicine has typically had such rigid standards to limit those errors to a small statistical error. But psychiatric diagnosis as viewed by many doctors has had too great a risk for wrong diagnosis. Truthfully this criticism from a scientific standpoint remains entirely valid.
The way diagnosis of a mental health condition (depression, anxiety, PTSD, etc.) works in the DSM is that a clinician looks at a list of symptoms for a diagnosis and if the patient/client has enough symptoms to meet a criteria for cutoff then they are considered to have that diagnosis. Sounds simple right?
There are two problems with this method. The first is that the decision about how many symptoms from the list constitute a diagnosis is arbitrary. To have PTSD you have to have one symptom out of a list of five. Generalized Anxiety Disorder requires three out of a list of six. No one can tell you how these numbers were chosen. Most professionals believe the cutoffs are arbitrarily drawn and there is little to no research to support the cutoffs. The second problem is that severity of the symptoms is rarely considered. For example, what if I have two symptoms for Generalized Anxiety (sleep disturbance, and being easily fatigued) and these symptoms are so debilitating that I cannot work everyday. Because I only have two symptoms I don’t have a diagnosis. Yet my two symptoms are so troublesome I cannot function in a normal manner.
These diagnostic precision issues make the actual diagnosis of a mental health condition suspect. It is important as a consumer of mental health services to understand the processes of diagnosis and their lack of precision.
2. Diagnosis is best made on a continuum of severity rather than a simplistic you have it or you don’t.
If you go to the doctor for a sore throat, they conduct various diagnostic tests that with statistical certainty are able to tell whether you have a bacterial infection (strep throat), a virus or even some more serious condition. The physical, biological markers that are able to be measured in a doctor’s office are absent when it comes to mental illness. There are not medical tests, or scans (including MRIs, CAT scans, or other brain images) that can conclusively diagnose a mental illness. All mental illnesses are diagnosed by grouping symptoms, and if you possess a large enough number of a particular set of symptoms you are considered to have a mental disorder.
One of the greatest additions and changes to the DSM 5 is a focus on measuring the severity of symptoms rather than a simple list. This is important because a person with five symptoms that only cause a mild disturbance for one individual may actually be experiencing less distress than a person who has three very severe symptoms. Rating the severity of symptoms help clinicians better understand the impact of symptoms on an individual’s day to day coping.
As clinicians better understand how a disorder, a condition, or even set of symptoms impacts the person’s day to day activities it aids in making a plan for treatment. Identifying the severity of symptoms allows improved planning for goals and direction for therapy.
As a consumer of mental health services it is important to realize that it remains a “soft” science, but improvements in diagnosis help a clinician with treatment planning.