The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the compilation of ten years of work by the American Psychiatric Association, representing the efforts of hundreds of high-level experts in the field of mental health. (1) Although the collective experience and expertise behind this manual deserves acknowledgment, the DSM classification system of mental health disorders needs to be rethought.
Many of us in the medical field have known of this problem since medical school. The criteria for a given diagnosis is vague and impossible to document, especially in a busy clinical setting, yet they are handed out like samples at a grocery store. Once a diagnosis hits a patient’s medical record, they have it for life. Due to the nature of the human brain, receiving a label becomes a self-fulfilling prophecy where people take on the identity of their diagnosis.
Too many vague choices
In clinical research, the more criteria that are needed to make a diagnosis, the less reliable it will be. A classic example in orthopedics is classifying proximal humerus fractures of the shoulder. There are only four choices, with the added descriptor of displacement. Even with CAT scans (providing a three dimensional view) in addition to X-rays, there is a poor consensus between surgeons on a given patient. (2)
A recent paper in “Psychiatry Research” looked at the five most commonly used chapters of the DSM system: schizophrenia spectrum and other psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, and trauma-and stressor-related disorders. (3)
In the introduction, they cited a couple of other studies. One showed there are almost 24,000 combinations for panic disorder in the DSM-5, and only one for social phobia. (4) The other paper was even more unsettling was that in the majority of diagnoses in DSM-5, 58% of people could receive the same diagnosis and not share any common symptoms. (5) This paper goes into great detail analyzing the problem of creating such specific diagnoses from multiple vague symptoms and perspectives. It seems clear that the DSM approach to mental health is unhelpful and potentially damaging.
My synopsis of the fallout created by the current situation:
- With the vast number of diagnoses, criteria to meet them, subjective interpretation of the symptoms and infinite uniqueness of each person, attempting to make a specific diagnosis that summarizes a person’s mental health makes no logical sense.
- Anxiety simply signals danger, whether it originates from a mental or physical source. It doesn’t matter if the threat is real or perceived.
- Avoiding anxiety is a major force that drives dysfunctional behaviors. These coping mechanisms are part of a massive unconscious, neurochemical survival reflex that is not subject to rational interventions.
- Anxiety needs to be removed from a psychological diagnostic category. There has been much basic science research in this arena for over 40 years, and in fact, Darwin hinted at the problem in the 1870’s. (6) It is simply the universal danger signal.
- Trauma is underrepresented in the DSM. Many of us have experienced some level of trauma. At what level does it become problematic and how would you quantify it?
- Being labeled in any realm covers up details. A significant number of us have several dysfunctional behaviors as a result of trying to run from our feelings of anxiety.
- The biggest issue is that the current approach isn’t working. By misdiagnosing and treating anxiety as a psychological diagnosis, our mental and physical health problems are escalating to the point where life spans are shortening. (7)
- Treating anxiety as a root cause of other behaviors allows the treatment provider to focus on the disruptive symptoms, difficult life situations, and provide support while the nervous system is calmed down and stress hormones are lowered.
- The DSM coding system works primarily for the benefit of insurance carriers and the business of medicine. It is not designed or intended be for a person’s benefit.
Doing the same thing
Over and over
And expecting a different result.
There are solutions to this problem and the experts who are familiar with the neurochemical nature of anxiety need to come to the forefront to lead the efforts to flip this paradigm.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM)) 5th Edition. Published by the American Psychiatric Association, 2013.
2. Foroohar, A, et al. Classification and treatment of proximal humerus fractures: inter-observer reliability and agreement across imaging modalities and experience. J Orthop Surg Res (2011); 6:38
3. Allsop, K, et al. Heterogeneity in psychiatric diagnostic classification. Psychiatry Research (2019); 279:15-22.
4. Galatzer-Levy, I.R., Bryant, R.A. 636,120 Ways to have posttraumatic stress disorder. Perspect. Psychol. Sci. (2013); 8: 651–662.
5. Olbert, C.M., Gala, G.J., Tupler, L.A. Quantifying heterogeneity attributable to polythetic diagnostic criteria: theoretical framework and empirical application. J.Abnorm. Psychol. (2014); 123: 452–462.
6. Porges, Stephen. The Polyvagal Theory. Norton and Company, New York, NY, 2011.
7. Woolf, S and H Schoomaker. Life expectancy and mortality rates in the United States, 1959-2017. JAMA (2019); 322: 1996-2016. doi:10.1001/jama.2019.16932.