Against A DSM Diagnosis

Joseph E. Davis is a contributor to the On Caring Blog

Many mental health professionals admit they don’t pay much attention to the Diagnostic and Statistical Manual of Mental Disorders (DSM). They recognize, correctly, that the diagnostic categories have little validity or clinical value. However appropriate and harmless this may be for them as professionals, though, they need to be aware of the DSM’s influence on their patients. My research suggests there are good reasons to believe that it can mislead people about the nature of their suffering and how they might respond to it.

For professionals, the DSM often serves a merely practical purpose. Therapists consult the field guide only to get the right diagnostic code for the insurance forms. Without a diagnosis, the third party won’t pay. Psychiatrists rely on the DSM somewhat more. In the pharmacological realm, treatment is supposed to be guided by accurate diagnosis and the symptom checklists and questionnaires typically used to make a diagnosis are loosely based on DSM criteria. But even here, the Manual often draws a shrug. As the therapist and writer Gary Greenberg reported after talking with “virtually every prominent psychiatric nosologist in the country,” nary a one would say that the DSM is of clinical benefit. Besides, both psychiatrists and regular physicians acknowledge prescribing the most common psychiatric drugs, such as the SSRI’s, on a trial and error basis, and, despite names like “antidepressant,” use them for a broad spectrum of conditions. When choosing treatment for these patients, the diagnosis isn’t very informative. The important question is what works to relieve distress.

Because they view the DSM as clinically inconsequential in the everyday cases, professionals often treat worries about the diagnostic categories as much ado about nothing. Don’t fret, they say, diagnoses are for administrative purposes and the needs of researchers. And, they add, there is one clear clinical benefit: Many patients find a diagnosis reassuring. It gives them a medically recognized name for their suffering that eases feelings of differentness, facilitates communication with others, and can suggest a positive prognosis. Otherwise, professionals insist, DSM categories are at best heuristic devices and patient experience is heterogenous. Treatment decisions are based on their clinical judgment of the needs of each patient. Consulting the DSM is unnecessary.

I am not a mental health professional, but the interviews I did for my book Chemically Imbalanced: Everyday Suffering, Medication, and Our Troubled Quest for Self-Mastery suggest that a sanguine attitude toward diagnosis misses something critical. What is missed is the role that the DSM has come to play in our society. DSM diagnostic categories have been widely popularized and are shaping how people understand and speak of their experience, a shaping that is taking place before they ever seek professional help. This influence does have an impact on treatment.

Many people do find getting a formal diagnosis comforting. A diagnosis of generalized anxiety disorder (GAD) helped Eric (a pseudonym), for instance, see that his problems are not “like me just being whacked out in my head or nervous or stressed about stuff that’s ridiculous.” GAD, he emphasizes, “is recognized” as a medical condition and in this framework Eric’s anxiety is “real” in a new way. GAD is something he has, a specific condition that affects many people and is not peculiar to his personality and his circumstances. Now his painful struggle to teach in a competitive and stressful school environment has an ontology—a reality independent of him—and an incipient explanation. While the diagnosis is, strictly speaking, a mental illness, Eric, like most people seeing regular physicians and therapists, doesn’t accept the idea that he’s mentally ill. He thinks the professional he’s seeing shares his view and, in fact, talk of diagnostic categories in clinical and popular venues often leaves out the unpleasant part about mental illness. For ordinary people like Eric, the very act of official naming gives anomalous experience a clear, knowable, and objective existence.

 So, while clinicians might take a dismissive view of the DSM, ordinary people do not. They didn’t get the memo from Thomas Insel, who, when director of the National Institute of Mental Health, argued that the problem with the DSM is that its disorder categories lack validity. The categories are not, in other words, “just like diabetes”—real entities in nature, independent of human observers. Consequently, the NIMH dropped the use of DSM categories in its research. Insel did allow that the categories were reliable—i.e., “clinicians use the same terms in the same ways”—but if you’re a patient, where’s the comfort in that? For them, as Eric attests, what makes a diagnosis valuable is that it confers social recognition and legitimacy on suffering by establishing its facticity. It is a thing he has, not his response to his situation.

 Further, for many people, and in popular discourse more generally, “real” suffering is physical. It is not, as another interviewee stressed to me, “just in your head” or something you can “just snap out of,” as another put it. The common belief was that a diagnosis establishes that the root cause of one’s distress is in the body. The DSM itself has an implicit biological orientation but has little explicit to say about root causes because little is actually known. The theory expressed in much current psychiatric research is that mental disorder arises from some complex interaction of biological, behavioral, psychosocial, and cultural factors. Every case is different in this view and an individual’s life experience is critical (see our blog post on N of 1). However, over the past two decades, the story that ordinary people have been exposed to is that conditions like GAD, depression, and the like reflect an underlying flaw in neurochemistry, a “chemical imbalance.” Many people I interviewed took this account with them to the therapist or doctor, having already appropriated a diagnosis from their exposure to family members, friends, popular media, or pharmaceutical advertising. This explanation mediated the way they understood their experience and what they expected from treatment.

But even for those who did not reference brain chemistry, the exposure to the medicalized language of the DSM appeared to have a clear impact on the way they related to their experience. One of the most striking features of the interviews we did was the typically thin, impersonal vocabulary people used to talk about themselves and their distress. The English language has more than four hundred emotion words. It was remarkable how few of these words the interviewees actually used. Though this was perhaps partly due to the interview context, there was a strong tendency to displace any richer emotional terms with the flat, homogenous language of symptoms and disorders. In telling their story, many reduced every negative feeling to being “depressed” or “anxious” and seldom made any mention of such complex emotions as jealousy, envy, betrayal, disappointment, embarrassment, or resentment that one might reasonably expect them to feel given their circumstances. Casting troublesome feelings in such mechanistic terms constrained how they perceived and evaluated the import of their experience and often seemed to foreclose further reflection or reassessment.

In our ever more bureaucratic world of health care, even diagnoses that lack validity and clinical value serve too many research, commercial, and administrative functions to be abandoned. Health professionals, however, need to be cognizant of how the extensive popularization of these categories has influenced the parameters of popular understanding and the pathways of potential care (see blog post on knowing and caring). And professionals would do well to avoid diagnostic language. Patients can be reassured by comparison to others in similar circumstances, but it is the complex interaction of factors—their particular situation, their emotional responses, their suffering—that needs to be addressed.