Shall we question the brand new book of human troubles

With three years still left until pub­li­ca­tion, the fights over the new ver­sion of the psy­chi­atric diag­nos­tic man­u­al, the DSM‑V, are hot­ting up and The New York Times has a bookcon­cise arti­cle that cov­ers most of the main point of contention.

- “What you have in the end,  Mr. Short­er said, “is this process of sort­ing the deck of symp­toms into syn­dromes, and the out­come all depends on how the cards fall.

- Psy­chi­a­trists involved in prepar­ing the new man­u­al con­tend that it is too ear­ly to say for sure which cards will be added and which dropped.

Although I doubt the DSM com­mit­tee are using that exact metaphor, it cer­tain­ly illus­trates the point that the process requires a cer­tain degree of value-judgement.

It’s inter­est­ing, how­ev­er, that the pub­lic debate is cur­rent­ly focused on whether cer­tain diag­noses should be includ­ed or not, rather than whether diag­no­sis itself is use­ful for psychiatry.

We’ve had psy­cho­met­rics for a good 100 years that allow us to mea­sure dimen­sions of human expe­ri­ence and per­for­mance with a much greater degree of accu­ra­cy than clin­i­cal diag­no­sis allows.

The slight­ly obses­sive need to clas­si­fy every­thing is both an inher­i­tance from the infec­tion mod­el of dis­ease, where one either has the pathogen or does not, and is encour­aged by the US health care sys­tem, where insur­ance com­pa­nies will only pay for treat­ment if it is diag­nosed with an ‘offi­cial’ diagnosis.

Nev­er­the­less, it is per­fect­ly pos­si­ble to treat some­one based on con­tin­u­ous mea­sures of dis­tress, impair­ment and func­tion­ing using evi­dence-based cut-off points to judge whether a par­tic­u­lar treat­ment should be applied.

In fact, many phys­i­cal dis­eases are treat­ed in exact­ly this way. The def­i­n­i­tions of obe­si­ty, hyper­ten­sion, dia­betes and many oth­ers rely on an evi­dence-based cut-off point on a con­tin­u­ous scale of weight, blood pres­sure and blood glu­cose level.

There is no qual­i­ta­tive­ly dif­fer­ent cut-and-dry dis­tinc­tion between just below the cut-off and just above it — it’s just the point at which out­come stud­ies pre­dict that oth­er things get much worse.

So rather than ques­tion­ing the process, we need also to ques­tion the sys­tem, because diag­noses are tools and we need to know when and where they are most useful.

Link to NYT ‘Psy­chi­a­trists Revise the Book of Human Troubles’.

Mind Hacks Vaughan BellDr. Vaugh­an Bell, main blog­ger at Mind Hacks, is a clin­i­cal and research psy­chol­o­gist inter­est­ed in under­stand­ing brain injury, men­tal dis­tress and psy­cho­log­i­cal impair­ment. He is cur­rent­ly at the Depart­men­to de Psiquia­tria in the Uni­ver­si­dad de Antio­quia and the Hos­pi­tal Uni­ver­si­tario San Vicente de Paul, in Medellin, Colom­bia, where he’s a vis­it­ing pro­fes­sor. He’s also a vis­it­ing research fel­low at the Depart­ment of Clin­i­cal Neu­ro­science at the Insti­tute of Psy­chi­a­try, King’s Col­lege London.


  1. Gregory on December 30, 2008 at 12:45

    Impor­tant topic.

    Diag­no­sis’s too often resem­ble a sentencing,…condemning a per­son to a sta­t­ic con­di­tion. Where in real­i­ty, noth­ing in life is sta­t­ic, espe­cial­ly the human mind. 

    It can some­times be a sim­ple mat­ter of mak­ing a sub­tle yet pow­er­ful shift in lan­guage. IE instead of stat­ing that some­one is (insert diag­no­sis here), it is much more accu­rate and less con­fin­ing to say that a per­son has a spe­cif­ic degree of (insert con­di­tion here).

    After all nobody is their condition…although many peo­ple end up iden­ti­fy­ing with ill­ness the way diag­no­sis are cur­rent­ly given.

    Thanks for excel­lent article.

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