This month the American Psychiatric Association will publish its fifth edition of the Diagnostic and Statistical Manual. This publication has been met with criticism and skepticism, much of it covered on this website.
As the medical director of a community mental health center, my colleagues look to me for guidance on how to approach this new edition. How many should we buy? How much time should be devoted to staff training? Although this is a book published by psychiatrists, it has become widely used as the basis for diagnosis by many clinicians.
I have written previously about what psychiatric diagnosis does and does not tell us. I am well aware of the many limitations of labeling something about which we have such limited understanding. As widely publicized, Thomas Insel, the Director of the National Institute of Mental Health published an essay on the eve of the publication of DSM-5 which essentially laid out the profound limitation of this guide.
People on this particular website may deride any service offered in a community mental health center like the one which employs me, but everyday people come to us seeking help. We are embedded in the social service network and the insurance system. This is all reliant on some sort of process to allow us the get paid for our services. That process is based on diagnosis.  The scope of the need goes far beyond seeing a psychiatrist. If someone is homeless and needs a voucher for a hotel, if someone needs a coach to help find a job, if someone wants help to stop abusing alcohol, if that person and his therapist agree to check urine samples to follow his progress, all of this requires someone – often me – to provide a diagnosis.
When I think about replacing this model, I have wondered whether it might be helpful to allow each citizen to draw from a fund at any point in her life without regard to a faulty diagnostic system. If a young person hits a rough patch where she seems unable to focus and has trouble staying at work, she could draw on this for a period of time until she rights herself without out having someone apply a label based on a system that so many people agree is flawed and lacking in validity. Another person might rely on this when a loved one was ill and needed care. This might raise the bar for requiring us to label a person as disabled or anything other than someone who for whatever reason needs a time out.
That is a thought. Probably not a realistic one. So what do I do in my own world now? My answer to my colleagues is to wait. I do not believe the DSM-5 is anything other than a code book. I think we will be able to find out for free how the codes have been adjusted and changed. We can look at the ICD system which is available on line. We have limited resources and it does not appear to me that they are well used in buying this book or retraining our staff.
Most importantly, we need to train our staff and talk to the people we serve about what these labels do not tell us. They do not answer what is wrong or what happened in a person’s life. These labels do not tell us who can recover. Even for those who believe that the drugs we prescribe may be helpful, the labels do not tell us much about what specific drug will be effective. So-called antidepressants, for instance, are used so broadly that the label makes little sense. Even for those who believe that we will understand extreme states by deconstructing the fundamental workings of the brain, these labels do not inform us about brain function or dysfunction.
On a positive note, perhaps the publication of the DSM-5 has prompted a much-needed discussion of the profound limitations of psychiatric diagnosis.
“Even for those who believe that the drugs we prescribe may be helpful, the labels do not tell us much about what specific drug will be effective. So-called antidepressants, for instance, are used so broadly that the label makes little sense.”
Dr. Steingard,
That’s a very good point – which applies to other psychopharmaceuticals no less.
And, this leads me to wondering why, in your recent series of blog posts on the, “Optimal Use of Neuroleptic Drugs,” you did not put that very same hyphenate (“so-called”) before this word, “antispychotics”?
Respectfully,
~Jonah
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For clarification…
Note: There is an inadvertent typo, in my comment, above.
(I had *not* meant to write, âantispychoticsâ — which sounds like a drug that the nefarious villain might slip into James Bond’s Vodka Martini…)
Hopefully, you’ve understood my simple intent — of aiming to bring attention this fact, that, here you are willing to use this qualifier, “so-called” before the word, “antidepressants,” yet your use of the word, âantipsychoticsâ goes unqualified (in your preceding blogs).
In my view, âantipsychoticsâ is a terribly *misleading* designation, for the neuroleptic drugs (which they refer to) are prescribed for all sorts of purposes; and, indeed, they can create ‘psychosis’ effects. (Such was the upshot of my own tortured experiences with them, many years ago.)
For these reasons, I believe this qualifying hyphenate, “so-called,” should be placed before any use of the word, “antipsychotics”.
~J.
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Hi Jonah-
I do not think I used the word antipsychotic in those blogs.
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Dr. Steingard,
You used it 5 times in the first blog (March 23); you used it 2 times in the second blog (March 30); you didnât use it in the third blog (April 14); you used it 2 times in the fourth blog (April 22).
This is to say, you used it 9 times.
That’s not counting times that you used it, by quoting others. (Of course, that sort of use can be unavoidable — and, really, necessary, at times, all things considered; and, in fact, I am not criticizing your use of the word…)
Simply, I wonder: Wouldn’t it be good had you said, “so-called antipsychotics” when you, personally, were employing that word (“antipsychotics”) in your blogging?
Respectfully,
~Jonah
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The context of that series was to specifically address the effectiveness of that class of drugs in reducing symptoms that are labeled as psychosis. Since the term antipsychotic drug is used in the literature, I sometimes used it in that context. I did not and do not think I erred in leaving out the words “so called”. Honestly, it did not occur to me to use it in that contaxt and I am not sure it would have added but you may disagree.
In the above blog, I was addressing the lack of specificity of these drugs. I happened to refer to the anti-dperessants but I could have easily referred to the anti-psychotics or anti-anxiety drugs. I do not disagree with your implicit point that all of these drugs are lacking in specificty.
Thanks for your careful reading of my posts!
Sandy
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“We are embedded in the social service network and the insurance system. This is all reliant on some sort of process to allow us the get paid for our services. That process is based on diagnosis.”
Given that the DSM is being publicly acknowledged as, simply put, bunk…well, I guess these systems of service provision will just have to change.
Thanks for not buying the DSM!
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And this has been my pointâŠeven if psychiatry was replaced overnight with survivor-led services how are your peers going to access service provision if theyâre not in your insurance system. Your health system is something of a nightmare vision to the UK, weâve seen the programme’s documenting how your poor are left with practically nothing, or massive debt.
You must know survivors who work for companies where the pay is so low they can avoid paying for health insurance with their workers requiring food stamps. American activists canât all have the decent health insurances, homes and better paid jobs.
Those of us who some of you would might define as âleftâ, âmarxistâ or âcommunistâ have this belief of collective responsibility. Our government is right wing with increasing state intervention into our lives and if it remains this way I can easily think of several key politicians who would say great we can just use the mental health budget for something else. The economic arguments and structures will need to be thought through for both our countries. Getting rid of DSM isnât the end point, itâs the starting point, and ârecoveryâ services will have to ensure they donât fall into the same trap as psychiatric tyranny with the âdo it our way or not at allâ.
As for DSM book – I wouldn’t using a copy for toilet paper!
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@Dr. Steingaurd
You wrote:
“On a positive note, perhaps the publication of the DSM-5 has prompted a much-needed discussion of the profound limitations of psychiatric diagnosis.”
With all due respect where I am with a UK NHS perspective the discussion is actually how many psychiatrists do we actually need? Do we need any? The fact is all they really do is diagnose and prescribe anyway….set times for observation intervals in acute wards. All of these things can be done by someone else. In the US psychologists are getting prescribing rights, same in the UK. Admissions are ultimately done by social workers in the UK, thats the legal position.
To be honest in the UK we have a system that can just about do totally without very very expensive characters called psychiatrists….I can assure you this isn’t just me….these conversations are taking place at the highest level in the NHS….just not out in the open yet….
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Dear Sandra,
Thank you for pointing out the very real dilemma individuals, families and providers in a “system of care” are facing. Truly, a “can’t-win-for-losing” dilemma that encourages individuals to ask for and accept diagnostic labels for insurance coverage, encourages parents to “disown” their adult children in acute distress so they can qualify for public aid, and encourages parents of young children to seek diagnoses to get learning accommodations in school settings.
With regard to parents of young children and classification systems, I recently witnessed a disturbing exchange during a presentation on supporting families with “children with severe mental illness.”
In response to the parent educators’ insistence that children need to be diagnosed early to get much-needed treatment and access to services, a parent and peer family worker shared that it was much better to get an autism diagnosis than a severe emotional disturbance diagnosis, because the latter has resulted in institutional discrimination for her daughter, who is no longer allowed to participate in after school activities, clubs, sports, etc.
Despite this discrimination and limiting of her child’s social opportunities, she had no overarching concern about labeling her child, just about picking the wrong label, as if we could pick and choose (well…).
I was stupefied as other parents then asked about which diagnoses were best for accessing services. There was no question, save in my mind, that the diagnoses themselves were a problem. Or that there might be another way to support our children’s divergent emotional and learning needs. My audible question to this effect met with blank stares. As did my question about using WRAP for Kids or acknowledging the role of trauma, resilience and developmental and attachment issues.
Brain disorders and diagnoses were far more interesting and, certainly, grease the wheels of insurance coding, office reimbursement and benefit payouts much more efficiently. A process we are all complicit in, as this exchange proved.
I’m not sure I have a better answer than your “safety net” insurance idea (which is not bad, by the way), but I guess I do fall back on the belief that we should avoid diagnoses altogether, if at all possible, especially when talking about children under 18 who do not have their own agency or sovereignity and for whom the effects of diagnosing can be catastrophic.
I really feel for the position you are in. So many people who so desperately need care and have to work within an imperfect system to get it. I appreciate you hanging in there and trying to make a real difference.
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“very very expensive characters called psychiatrists”
I just asked, on another comment thread, why it is not illegal for non-specialized (or, specialised, in the UK) practitioners to prescribe drugs that act upon the human brain. So, what are the trainings and certifications that psychiatric prescribers have to have before they can prescribe psych. Meds and where does conscientious prescribing and harm reduction come into play?
This is not to say that psychiatrists, as a rule, know about the brain (many evidently do not) or that psychiatrists, as a rule, practice anything like conscientious prescribing or harm reduction.
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@Faith
I missed your comment on another thread. (isn’t it odd that the comments section is over loaded but the forum section of MIA is almost dead)…that aside…
For myself I try and get away from speaking or writing about the brain as a special organ. Clearly it is certainly different from other organs and has some special qualities in some way but the trouble is it is also part of the endocrine system for instance…its a very messy picture as I’m sure you know…
For me the questions are not so much about “the drugs affect the brain” because lots of things do that…it’s the power to use force that I object to….the fact that psychiatrists use their power to act mostly on the brain to me is (almost) beside the point. If a psychologist had the power to force me to sit through endless mind numbing therapy sessions I would object just as strongly….
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If a psychologist had the power to force me to sit through endless mind numbing therapy sessions I would object just as stronglyâŠ.
Amen to that, never underestimate the power of unwanted psychological interventions just because it doesnât directly damage the brain. Peer pressure, loss of âprivilegesâ, and punishment of a group if they donât all comply is the stuff of nightmares and I too would fight as hard against that as forced physical treatments.
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The fund you refer to Sandra, it requires more than that because some survivors will simply never fit traditional working patterns or canât work enough hours to be fully self-sufficient, and some need to remain doing voluntary work and this is one of the problems with our political systems, ours dictates that people are only worth their economic productivity and that âwork is the solutionâ, but it isnât always.
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This is all very interesting and I always wondered why the DSM was such a big deal and it always led to the labeling and insurance aspects. What has not been mentioned and is very scary to me as a professional,parent, and client is that the community mental health centers are at the mercy of paperwork and productivity documentation. There are professionals who job for the government and insurance is just to peruse records and see if they can find a mistake that would invalidate the progress note and the center would not get paid. On the other side of the Looking Glass are professionals in the Mental Health Center( that I am sure the good doctors knows well) who go through the progress notes and records making sure those types of mistakes are taken care before the credentialing and other folks come and do their own reviews.
In the early eighties we could have 3 hour and a half sessions to make a diagnosis and we had the option of NOS. Not otherwise specified. This was a label that I loved and used frequently.
So much has changed and the folks coming into Community Mental Health Centers to work are not aware of the past and accept what is now happening as adequate.
Special Education is a separate but somewhat similar ball of wax.
Lables in some states are weighted that is if you have the diagnosis of TBI ( traumatic brain injury) the school is given more money) in the mid nineties TBI was big in my state and my son was one of the first to carry that diagnosis which lasted until a twenty minute pedsneuro assessment changed it to Autism. The fact that he could have both diagnosis never passed any professionals mind except my own. And he still doesn’t fit any category so he is basically on his own. Very High level functioning except for socialization with peers and fine motor skill issues.
The issue in IEP’s ( individual education plan) is that you do have to fit into a mold to get services and even then the services are only for a certain level. PT and OT services are only for school related issues. Family dinner and restaurant issues are not allowed. Teachers spend hours of extra time with the IEP. It was originally a great idea. All children should have one but it has gone into the dust with the bureaucracy.
The cauldron seems to be bubbling which is a good thing. Look at TB and the diseases that seem so simple now but lead many professionals to do things that simply did not work at all.
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Instead of an all-out boycott on the DSM-5, why not have a healthy compromise?
The APA can provide a half-dozen copies for the National Library of Congress, to be loaned to any citizen interested.
They can later be placed in the upcoming ‘Death of Psychiatry’ exhibit in the Smithsonian Museum of American History for *all* to enjoy.
A win-win.
Duane
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A half dozen may be too many.
Three should suffice.
Duane
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Very sensible decision, Sandy. I hope many clinics and doctors decide to spend their scarce dollars elsewhere.
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