Mental Illness — Comprehensive Evaluation or Checklist?
by Paul R. McHugh, M.D., and Phillip R. Slavney, M.D.
New England Journal of Medicine 2012 366:1853-1855.
The debate over revising the Diagnostic and Statistical Manual of Mental Disorders is of more than intramural interest, for the way in which the promised fifth edition (DSM-5) resolves the debate will shape the nature and scope of psychiatric services for years to come. Now established as the master reference work for U.S. psychiatrists, the DSM initially emerged, like the companion volume for internists, the International Classification of Diseases, with a public health interest in the incidence and prevalence of illnesses. But with its third edition in 1980, the DSM began prescribing how clinicians should identify psychiatric disorders. The editors of the DSM-III justified this move by noting that the likelihood of diagnostic agreement between any two psychiatrists about the same patient was scarcely better than that achievable by chance. They attributed much of the difficulty to sectarian discord among proponents of psychodynamic, behavioral, and neurobiologic explanations of mental illness. And they concluded that the diagnostic muddle could be cleared up if psychiatrists put aside disputes over causes and instead identified disorders by their symptoms, signs, and clinical course.The DSM-III produced a revolution in psychiatry. The manual identified every condition with lists of diagnostic criteria; its editors presumed that causes, mechanisms, and rational treatments of the conditions would emerge through investigative efforts that, supported by these reliable definitions, drew from the boundless explanatory resources of the biopsychosocial body of knowledge. Revolutions solve some problems — but usually raise others that are unintended and unexpected. The DSM revolution was no exception. The diagnostic approach based on clinical appearances, one akin to using a naturalist’s field guide, proved to be a tactical success in that it stilled sectarian conflict, but a strategic failure in that it offered no way of making sense of mental disorders — that is, no better answer to the question “What are they?” than a multitude of examples. Undeniably, the DSM-III brought some gains to psychiatric practice, including consistency of diagnosis, uniformity in therapeutic regimens, and confidence in clinical research based on the reliable inclusionary and exclusionary criteria that DSM diagnoses can provide to investigators. Many psychiatrists who recollect the discord within psychiatry before the DSM-III find these gains sufficient. In their view, the subsequent revised editions corrected the flaws that remained.
I’m obviously not one of those psychiatrists who thought the DSM-III fixed anything. I was an Internist who had changed specialties to psychiatry in 1977 drawn by the case history method of psychiatry – maybe I should say compelled. As a practicing doctor, I ran across plenty of cases of mental illness and the more I knew about the patient, the clearer things got. I had trained in medicine at a school that was in the biological psychiatry belt between St. Louis and New Orleans, so I’d never been exposed to the case history method [a term I just made up]. In practice, I met some psychiatrists trained elsewhere who knew how to take the clarity of a comprehensive history and use it to help their patients. It wasn’t long before I was applying to a psychiatric residency which turned out to be exactly what I wanted it to be.
It was the time of the DSM-II. I don’t recall ever reading the words under the headings. I used it like I’d used similar books in Internal Medicine – to look up the numbers for filling out forms – a book of codes. I didn’t know it was psychoanalytic until after I retired and started writing about the current problems within psychiatry. I don’t think I really knew that the DSM-III was part of why psychiatry changed on me early in my career until around the same late date. I think I saw it as an unfamiliar book with way too many words between the diagnoses and their code numbers. But I sure knew psychiatry changed, and that case history types like me were no longer welcomed in academia, so I either left or was extruded [actually both] because I wouldn’t or couldn’t change [also both]. If I’m honest, I don’t even really think I knew what I was being asked to change into.
Yet the publication of a fifth revision of the DSM — now promised in 2013 — has been repeatedly postponed, mainly because fundamental problems tied to the approach of the DSM-III proved hard to solve. A most serious problem, common to field guides, is the difficulty of separating entities that are similar in appearance. For example, psychiatrists using the DSM diagnosis “major depression” tend to mingle bereaved patients with both those afflicted by classic melancholia and those demoralized by circumstances…
That’s one of the things that I didn’t understand back then – that specific mingling of depressions seemed like mixing very different conditions together. I still don’t understand it. I just thought it was wrong, like somebody had made a gigantic mistake so I ignored it. I still feel that way.
Many issues of concern derive from another change in practice that the DSM-III inadvertently encouraged. Its emphasis on manifestations persuaded psychiatrists to replace the thorough “bottom-up” method of diagnosis, which was based on a detailed life history, painstaking examination of mental status, and corroboration from third-party informants, with the cursory “top-down” method that relied on symptom checklists. Checklist diagnoses cost less in time and money but fail woefully to correspond with diagnoses derived from comprehensive assessments. They deprive psychiatrists of the sense that they know their patients thoroughly.
It’s remarkable to read something this clear in my old haunt, the New England Journal of Medicine at a time when I’m parsing the ontogeny of the DSM-5. I guess the Internist is still in me more than I knew. I made this very argument until I got tired of it being discounted as psychoanalytic, Freudian mumbo jumbo. I knew that wasn’t right, but I knew when I was licked. I had been forced out of a research laboratory into medical practice by a draft notice. Once practicing, I loved doing it and made a change of specialty, pretty dramatic, to practice better what I was most interested in. So here I was again, in academic medicine teaching what I’d learned, and being forced out into practice again [this time more voluntary]. I liked practicing even more the second time.
Moreover, a diagnostic category based on checklists can be promoted by industries or persons seeking to profit from marketing its recognition; indeed, pharmaceutical companies have notoriously promoted several DSM diagnoses in the categories of anxiety and depression. Together these problems expose a critical issue of design in the DSM. By forgoing thought about causation in identifying psychiatric disorders, the manual promotes a rote-driven, essentially rule-of-thumb approach to the diagnosis and treatment of patients — and there is no obvious way of escaping the practice…
Well, it can be escaped. Just don’t do it [because it’s silly – an affront to the practice of medicine and our patients]. Seems pretty obvious to me. Back in the day, biological psychiatrists and researchers were my colleagues and friends. They taught us the science of mental illness, about the brain and the drugs. I went to the conferences, read the journals, was excited about the possibility of biomarkers. The dichotomy came later. And now, though it may sound arrogant, I don’t need the DSM-5 Task Force obsessing about what psychiatrists need to do, how we ought to practice. I honestly think I know more about that than they do for the simple reason that I’ve done a lot of it rather than just thought about doing it. I have no idea about what to do about psychiatric finances. I never dealt with third party carriers directly and I didn’t bill insurance for my own analysis or for that of any patient. Mostly, I was the case history bottom-up doctor I set out to be. It had become my dream…
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