1 Boring Old Man

di·ag·no·sis [dg-nss] n. pl. di·ag·no·ses [-sz] 1. Medicine a. The act or process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination, and review of laboratory data. b. The opinion derived from such an evaluation. 2. a. A critical analysis of the nature of something. b. The conclusion reached by such analysis. 3. Biology A brief description of the distinguishing characteristics of an organism, as for taxonomic classification. [Greek diagnsis, discernment, from diagignskein, to distinguish : dia-, apart; see dia– + gignskein, gn-, to come to know, discern; see gn– in Indo-European roots.]

When I was in training, I don’t recall diagnosis being a major preoccupation in psychiatry, but that was the dawn of time. Compared to Internal Medicine, my former haunt, things were pretty simple. The complexity was in the individual’s story, not in his/her categorical assignment. In 1980 with the DSM-III, things did become more complicated and there was a major preoccupation with diagnosis. I expect many clinicians didn’t pay a lot of attention to the difference except in administrative matters. It was clear over time that the radical change was to certify psychiatry as a medical specialty and not a psychological or psychoanalytic specialty. As psychiatry itself became increasingly focused on neuroscience and pharmacologic treatments, the diagnostic system remained in the descriptive, non-commital mode. That’s where it will be in a couple of weeks when the DSM-5 will be released, in spite of its leaders earnest attempts to make a transition to a biological classification.

Is that why there’s so much controversy about the DSM-5, that they tried to make it into a biological classification? They put biology in the definition, and biology has been all they talked about along the way, so maybe that did bother people who don’t agree that biology covers the domain of mental illness. But I don’t think that’s the bottom line reason for all the discord. It’s no secret that most academic psychiatrists are biologically oriented. So, since the DSM-5 isn’t really that different than the DSM-IV, why has there been so much dissention?

Well for one thing, they were up against some class act critics – Drs. Robert Spitzer and Allen Frances, their predecessors in previous revisions. Their continuing to ignore the problem areas like Major Depressive Disorder garnered a lot of criticism from respected biological researchers. The psychologist community was marginalized by their biological preoccupations. And their decision about the bereavement exclusion offended everyone. To say that they didn’t manage criticism very well would be a massive understatement.

But I think the real reason for all the bru-ha-ha was more intangible than any of those specifics. They didn’t revise the diagnostic manual, they "tweaked" it. There’s nothing in the DSM-5 that refines our ability to discern or distinguish apart. No diagnosis is any clearer than it was last time around. They didn’t even talk about that in the process. The changes they made were to change the thresholds for diagnosis. Those changes were monotonous in that they universally lead to more indications for medication. And in areas like Major Depressive disorder where overmedication is already rampant, they even brought more into the fold. With the fictive Bipolar Child category, they just gave the group a new name. Little doubt how the kids will be treated. So they "tweaked" the DSM-IV to suit their psychopharmacologic view of treatment instead of engaging it and trying to make it more accurate and more useful.

They sequestered themselves planning to put the finishing touches on a paradigm shift to an all biologic manual. Failing at that, they opted to expand the scope of pharmacologic treatments, and it’s obvious to anyone who looked. We don’t think of the DSM-5 as a revision. We see it as a power play. They didn’t fool anybody and they sure pissed a lot of us off in the process…