Making the Case For A More Streamlined DSM-5: A Few Suggestions
Our mental health bible is in need of a facelift. My diagnostic confidence is not bolstered by the DSM-IV-TR, and as proposed, the DSM-5 is not generating much enthusiasm for me either. So I got to wondering what a more user-friendly, more helpful DSM-5 would read like.
Before tackling this, here’s my two cents regarding the DSM-IV: the loosely-defined nature of this manual’s criteria has made it ripe for overdiagnosis in many instances. And overdiagnosis invariably leads to overtreatment because definitions are applied indiscriminately, misinterpreted, or simply ignored – often by overworked, undertrained primary care physicians who are entrusted with the lion’s share of care these days.
DSM-5’s most important task should be to do all it can to encourage a return to diagnostic responsibility. Here are a few suggestions for how to do this:
- Reel in diagnostic exuberance. The text should not be party to promoting diagnosis expansion. We’ve got too many already and expanding the criteria for current diagnoses takes us yet another step closer toward pathologizing the symptoms of everyday life. Diagnostic expansion conceivably could lead to the point where practically everyone will qualify for a mental disorder. The way things are going, sadness over a hangnail will be diagnosable while the seriously mentally ill will be increasingly neglected due to a lack of attention and shrinking resources. Also, it’s a no-brainer that any diagnosis that has grown exponentially over the last few years (think childhood bipolar) qualifies as a fad and is being carelessly assessed. The human condition hasn’t evolved fast enough to justify a 40-fold increase in any disorder. Diagnostic habits change when one is pressured by time constraints and influential prophets.
- Drop the sections on prevalence, course and recording procedures. Some of you may find this helpful, but I don’t. Over the years, I’ve rarely paid any attention to these sections. The prevalence and course of a disorder don’t help me get any closer to its appropriate assessment; nor do these sections contribute to diagnostic assuredness. As to recording procedures, we clinicians are beholden to the policies of the insurance companies and we’d better comply.
- Add a portion of text – that includes instructions and a sequence of steps – which teaches clinicians how to go about making a diagnosis. Doing this could be especially helpful to less experienced clinicians who haven’t been exposed to numerous client presentations. Many graduate schools are woefully inadequate at teaching diagnosis, and student field placements are so diverse, many, if not most graduate practitioners will bring an ill-equipped diagnostic skill set to the workplace.
- Diagnoses which are ripe for overuse should be clearly flagged. The culprits in need of such attention include: ADHD, generalized anxiety, autism, bipolar, MDD, PTSD and practically any NOS, at a minimum. Each of these suspects should be accompanied by statements that warn clinicians and patients of the ways it has been overused and under what circumstances it can be properly assigned.
- Tighten and strengthen the criteria for some disorders. For many disorders, criteria are just too nebulous and lack teeth. Overlapping symptoms can also be troublesome when considering differentials, but skilled diagnosticians know how to sift through this issue. Strengthening and tightening up criteria could potentially lead to a decrease in diagnostic callousness and carelessness and reinforce the fact that diagnosis is serious business and not merely an exercise pursuant to getting paid.
The diagnosis of mental disorders is highly nuanced, complex, is not subject to black-or-white judgments and can be downright hard. The suggestions discussed above can help us get better at it.
Joe Wegmann is a licensed clinical social worker and a clinical pharmacist with over 30 years of experience in counseling and medication treatment of depression and anxiety. Joe’s new book, www.pesi.com. To learn more about Joe’s programs or to contribute a question for Joe to answer in a future article, visit his website at www.thepharmatherapist.com, or e-mail him at firstname.lastname@example.org.