Search Search

How to Use the DSM

January 27, 2011
James Phillips, MD , James Phillips, MD

Relevant Topics

In my previous blog, The Missing Person in the DSM, I

questioned whether the DSM diagnostic manual
classifies psychiatric disorders or the individuals
suffering from diagnostic disorders-Ms Smith’s bipolar
disorder, or Ms Smith, a person with bipolar disorder.

In my previous blog, The Missing Person in the DSM, I

questioned whether the DSM diagnostic manual
classi es psychiatric disorders or the individuals
suffering from diagnostic disorders-Ms Smith’s bipolar
disorder, or Ms Smith, a person with bipolar disorder. I
noted that, following medical tradition, the manual
classi es diseases-not surprising since, in a medical
nosology, we expect to see hypertension and diabetes,
not Mr Jones’ hypertension and Ms Harris’s diabetes.

I also pointed out that this strategy works better in a

medical than a psychiatric nosology, since psychiatric
conditions are more interwoven than medical
conditions into patients’ personalities and lives. Both
doctor and patient can more readily treat Mr  Jones’s
hypertension as simply a case of hypertension than
can either treat Ms Smith’s bipolar disorder as just
another case of bipolar disorder.

The conclusion of these re ections is that when we

follow the medical model and leave the person out of
the diagnostic model, we know too little about the
person. Our patients often t our diagnostic
categories rather poorly-cheap suits from the bargain-
basement rack, to borrow a metaphor from the
previous blog-and we are forced to squeeze them into
the Procrustean beds of our existing categories-or, in
the much bruited routine of DSM-IV, to individualize
them with the clumsy tactic of comorbidity-or in the
equally bruited promise of dimensions in DSM-5, to
individualize them with dimensional scales.

So what to do? How do we return the missing person

to the manual? As I mentioned in the previous blog,
the WHO International Guidelines for Diagnostic
Assessment (IGDA)1 has proposed a dramatic and
quixotic approach to this problem: create a narrative
dimension to the manual, effectively providing each
patient with a diagnostic statement that is the
equivalent of a full psychiatric evaluation. This is at
once a solution and a non-solution. It is to lift the full
evaluation that should be part of any patient’s chart
and make it part of the diagnosis.

Here’s an alternative proposal for resolving the

problem of the missing person in the DSM. In a word,
eliminate the problem by forgoing this expectation of
the DSM. Give up your expectations that the manual
should tell you what is essential in your assessment
and treatment of your patient. Think of it rather as a
crude guideline that, we hope, will land you in the right
diagnostic ballpark-and not much more. When we
have given Ms Smith the diagnosis of bipolar disorder,
that’s not the end of our assessment, it’s barely the
beginning. We now have to get to know her, and gure
out how to conduct our treatment. We don’t expect to
nd her in the manual; we will nd her in our
consulting room.

This approach is of course good for the clinician but

not for the researcher, and it ies in the face of the
DSM dogma that the interests of the two groups are
the same. In fact, they are not. The clinician is
interested in helping Ms Smith; the researcher is
interested in studying bipolar disorder. These interests
of course overlap, but they hardly coincide. Debates,
for example, over the criteria for a major depressive
episode-whether the requirement of only 2 weeks of
symptoms and only 5 of 9 of the criteria casts too
wide a net and leads to over-diagnosis-is certainly of
scienti c importance; but it plays little role in day-to-
day clinical practice.

Am I being overly cynical about how to use the DSM?

Perhaps so, but I would at least argue that my
suggestions do little more than re ect how we already
use the manual. Clinicians have not lost the person;
they just don’t expect to nd him or her in the manual.
Let me end with the example of a prominent,
respected-and unnamed-clinician, as related by Gary
Greenberg in a recent article:

I recently asked a former president of the APA how he

used the DSM in his daily work.
He told me his secretary had just asked him for a
diagnosis on a patient he’d been
seeing for a couple of months so that she could bill the
insurance
company. “I hadn’t really formulated it,” he told me. He
consulted the DSM-IV and
concluded that the patient had obsessive-compulsive
disorder.
“Did it change the way you treated her?” I asked, noting
that he’d worked with her for
quite a while without naming what she had.
“No.”
“So what would you say was the value of the
diagnosis?”
“I got paid.”2References1. IGDA Workgroup, WPA.
IGDA 8: Idiographic (personalised) diagnostic
formulation. In: Mezzich JE, Berganza M, von Cranach
M, et al (eds). Essentials of the World Psychiatric
Association’s International Guidelines for Diagnostic
Assessment (IGDA). Br J Psychiatry Suppl.
2003;45;S55-S57.
2. Greenberg G. Inside the battle to de ne mental
illness. Wired, Dec 27, 2010.
http://www.wired.com/magazine/2010/12/ff_dsmv/al
l/1.