Treat Patients, Not Disorders: The Problem with DSM diagnoses
The DSM (Diagnostic and Statistical Manual of Mental Disorders), currently in its fifth edition, is the most commonly used diagnostic system for mental health disorders in Ontario.
I remember being taught that it was originally designed to standardize diagnoses so that clinicians could communicate to each other accurately when discussing a patient. It was meant to be descriptive in nature.
Over the years its use has expanded and it categorizes patients in research studies of all kinds and as eligibility criteria for health insurance coverage. It is also influential in how we conceptualize mental health disorders and how we design our clinics. There have been a plentitude of publications discussing the benefits and consequences of using a diagnostic system such as the DSM, most of them making valid points. There have been a number of serious concerns about the effects of using the DSM system.
They include the de-contextualizing of mental health disorders that otherwise could be understood as reaction to adversity, such as poverty, discrimination, trauma, and abuse. The use of diagnoses from DSM also redefines a lived experience into a medical illness, where only the expert advice matters and more often than not, is primarily focused on medication. Even large government agencies like the national institute for mental health in the U.S. have decided to move away from diagnoses based primarily on symptoms.
In spite of these concerns, the DSM remains a powerful communication tool when trying to describe a patient’s symptoms and so it remains in a somewhat modified and expanded, but relatively stable state. The world of psychiatry is not quite ready yet for a paradigm change. However, recently, I realized that these diagnostic categories actually now shape the way we think of mental health problems and influence the way we treat them.
Last week, a woman I work with asked me what she should focus on first, her obsessive compulsive disorder (OCD) or her eating disorder (ED). I did not have an answer for her. How could she deal with one and not the other? They were so intertwined.
Both involved counting, measuring and worries about contamination. Both affected what she did in her kitchen. It was not clear to me where one started and the other ended. I realized she did not have an ED with a comorbid OCD or OCD with comorbid ED, depending on who assessed her, she in fact simply had one disorder: EDOCD.
She had one mental health problem that manifested in her eating and in compulsive behaviours. It was the psychiatric world that taught her to slice and dice her experience into neat little packages according to diagnoses. We even organize treatment clinics according to diagnoses and then we exclude the co-morbid disorders that do not interest us. This is particularly true in academic or specialty centres. Anyone can find a clinic to treat OCD, but not one that will also treat your ED. One can attend an inpatient program for an ED, but not if there is a current active substance abuse disorder-you have to have treatment for that first. But, the substance abuse program won’t provide treatment if you have a co-morbid ED.
What happened to treating patients and not disorders?
It seems that what started out as a way to describe what we were seeing has turned into our viewfinder. I worry that this view through the DSM lens, is compromising patient care. I am not sure what the solution will be, but we must challenge our comfortable assumptions. Maybe we need to think about a person’s symptoms, in the context of their lived experience and focus on relieving distress and improving quality of life and function. Maybe it is about focusing recovery. Maybe diagnoses should only be used in reports to colleagues as a communication tool, as they were originally intended.