To the Left and the Right of Dr. Frances

Allen Frances continues to erect his wall of criticism of DSM-5.  He shows no sign of slowing down even after the DSM-5 was released.  He has written a list of 18 problems in the Psychiatric Times that he characterizes as "glaring mistakes in wording and coding."  He believes that there were "egregious mistakes on almost every page I read."  That is a curious counterpoint to the opinion I heard recently from Jon Grant, MD when he presented the history, process, and details of the development of DSM-5. While Dr. Frances has undeniable DSM-IV experience there is always plenty of room for disagreement.  He comments that he has limited time for a detailed read of DSM and I have even less, so I will concentrate on 2 of his 18 points to illustrate what I mean.

Intermittent Explosive Disorder - Dr. Frances main complaint about this diagnosis is that is "lacks the needed exclusions to exclude the other more common causes of violent behavior."   The diagnostic criteria actually contains the exclusion:

F.  The recurrent aggressive outbursts are not better explained by another mental disorder.....and are not attributable to another medical condition.....or to the physiological effects of a substance.

Specific examples are given and there is also an exclusion for adjustment disorders in children.  The actual number of exclusionary diagnoses listed are essentially the same as DSM-IV and the discussion in the differential diagnosis is more extensive (p 612-613).  My problem is that I don't think this diagnosis actually exists.  That statement comes from over two decades of experience in acute care inpatient psychiatry, community psychiatry, and hospital psychiatry.  These are all settings on the front lines of aggressive behavior.  When the police encounter aggression and there is any question of an intoxication, medical problem, or mental disorder associated with that behavior - those people are brought in to settings where acute care psychiatrists are  involved.  In my experience of assessing extreme aggression up to and including homicide I have never seen a single case where the outbursts were not better explained by another mental disorder.  I don't agree that the exclusion criteria are any different.  I don't believe that this disorder exists.  If it does, the prevalence is so low that this acute care psychiatrist has not seen it in thousands of evaluations of aggressive behavior.

Mild Neurocognitive Disorder - Dr. Frances complaint about this diagnosis is "so impossibly vague that it includes me, my wife and most of our friends.  It will cause unnecessary worry and a rush to useless and expensive testing."

As I read through these criteria I have a much different perspective.  For about 10 years I ran a Geriatric Psychiatry and Memory Disorders Clinic where we did comprehensive assessments of patients with cognitive problems.  I worked with a nurse who would collect detailed information on patient's functional and cognitive capacity before they came into the clinic for my assessment.   A significant number of those patients had a strictly subjective complaint about their memory or cognition.      A large percentage of these patients did not have any insight into the severity of their problem and their typical assessment was: "My memory is no different than any other 60 or 70 year old."  Even though we had generally spent about three hours of assessment time with each patient, at the end of my evaluation we often did not have a clear diagnosis.  We would stick with that person until we did and often times the outcomes were surprising.  We had striking examples of chronic delirious states where the patient was given a diagnosis of dementia based on on neuropsychological testing, and with treatment and reassurance we observed their cognition to clear completely and they were restored to normal cognitive function.

I see the diagnosis of Mild Neurocognitive Disorder as a portal to that level of care.  Based on the list of 10 brain diseases and other medical conditions listed as specifiers the authors of this criteria clearly had that intent.  It is clear to me that any clinic with a high standard of care for patients with cognitive disorders like my clinic had can use this diagnosis both as part of the continuum to more Major Neurocognitive Disorders associated with progressive neurodegenerative dementias and to provide high quality assessments for patients with concerns about any cognitive changes.  Keep in mind that the typical managed care model would use a crude screening test and possibly refer for other psychological testing.  There might not be a physician in the loop who can make the necessary assessments and diagnoses.  Current research in this area also points to the need to identify patients as early as possible, especially as treatments become available.

On these two points I guess I am to the right of Dr. Frances on Intermittent Explosive Disorder and to the left on Mild Neurocognitive Disorder.  But I think the entire argument misses the mark if we think about the issue of psychiatric diagnosis and where the DSM fits in.  Any DSM cannot be used like a phone book to classify hundreds of different presentations to a Memory Disorder and Geriatric Psychiatry Clinic.  The unique conscious states of those individuals and their relative levels of impairment can only be determined by a comprehensive evaluation by a physician who is knowledgeable in all of the possible brain diseases that are suggested as etiologies.  Apart from the obvious increase in complexity for anything that is determined by a central nervous system, getting a diagnosis of Mild Neurocognitive Disorder is no different than getting a diagnosis of "Neck pain" or "Ankle pain" from a primary care physician.  And yes - those primary care diagnoses are very common.

The idea that there are precise criteria that can be written down and applied to make definitive diagnoses is a common misconception of the DSM and other diagnostic schemes.  To emphasize that point, I will end with a quote from Harold Merskey, FRCP, FRCPsych:

"Medical classification lacks the rigor either of the telephone directory or the periodic table."

That is all medical classification and not just the DSM-5.   A good starting point toward realizing the truth in this quote is to stop looking at the DSM-5 like it is a phone book.  You don't get a psychiatric diagnosis from the DSM-5.

You get a psychiatric diagnosis from a psychiatrist.

George Dawson, MD, DFAPA

Merskey H. The taxonomy of pain. Med Clin North Am. 2007 Jan;91(1):13-20, vii. PubMed PMID: 17164101

The Latest Proclamation by Allen Frances

Just when you think that Allen Frances has run out of editorial venues for his anti DSM5 critiques another one pops up.  This time it is in the Annals of Internal Medicine.  This is a note about that process before I get into addressing his repetitive critiques.  The Annals is a respected medical journal.  For a number of years I was an ACP member and subscribed to it myself.  Why would the Annals go along with publishing an editorial piece that is basically a rehash of what has been published in the New York Times and the Huffington blog and who knows where else?  There is really precious little science involved.  I think the only logical explanation is that the staff of the Annals has jumped on the popular bias against psychiatry that has been widely noted in the press by Claire Bithell and her group that studies these issues.  I am not a current subscriber to the Annals but the question is whether there was equal time for rebuttal.  If not is this professional bias against psychiatry?

Probably the best way to address this rehash of old criticisms is to link up to previous blog posts here where that occurs.  Beginning in paragraph one Dr. Frances cites a famous study about pseudopatients as though it has some applicability to the issue of “unreliable and inaccurate” psychiatric diagnosis.  He cites this study as if it is somehow relevant to the problem.  All of the considerable scholarship refuting this study as meaningful by various authors including Spitzer and Kety is ignored.   Using this as a premise for a scholarly article on the validity of psychiatric diagnosis should raise an eyebrow or two, but on the other hand I doubt that there is anyone on the editorial board at this Internal Medicine journal who is familiar with this literature.

The issue of diagnostic inflation is a frequent critique used by Frances and others to suggest that this invalidates the DSM5.  Most people are very surprised to learn that compared to previous editions and the ICD-10 this is really not an issue.  The previous blog post illustrates that compared to the ICD-10, the possible increase in diagnostic categories in the DSM is trivial.  The increase in the number of codes for a knee fracture alone approximates the total codes in the DSM!  Contrary to his description of “holding the line” with DSM-IV diagnoses – the data presented in that post shows that the DSM-IV added twice as many diagnoses as the DSM5 will.

Dr. Frances uses the “no bright line” approach to say that there is no way to separate the worried well from people with disorders.  There certainly is no written “bright line” in the DSM.  Every DSM has a section with qualifying statements about its use and that fact that diagnostic criteria alone are not sufficient.  A psychiatric diagnosis, especially a diagnosis made by psychiatrists in the same group with the same focus is very consistent and it is a reliable marker of illness severity.  Professional judgment is required.  The “no bright line” issue is not a problem that is unique to psychiatry.  It is omnipresent in general medicine with regard to chronic pain diagnoses, chronic pain treatment, and in the overprescription of pain medications and antibiotics.  The overprescription of antibiotics has been identified as a problem by the Centers for Disease Control (CDC) for 20 years and recent authors suggest that minimal progress has been made.  It seems that other specialties are subject to the “fallible subjective judgments” suggested in this article.

Another implicit myth used by Dr. Frances and other critics of psychiatry is that there is some magical diagnostic process that occurs in medicine and surgery that makes them better than psychiatric diagnoses.  What happens when we test that theory by looking at the reliability of general medical diagnoses?  Looking at that data, it is clear that the published reliability data from medicine and surgery is no better than the frequently criticized data from psychiatry even when objective medical tests are used.  Practically everyone I know has a favorite story about a misdiagnosis and/or ineffective treatment of a medical or surgical problem.  That evidence does not support the contention that psychiatry is somehow less accurate or effective than the rest of medicine.  Some medical specialties used similar descriptive techniques even when they have numerous biological markers of the illness.  The other elephant in the room on this diagnosis issue is medically unexplained symptoms.  The studies of all patients coming in to a clinic setting suggest that 30%  do not get a diagnosis to explain their symptoms.  These patients often get multiple tests looking for a cause for their problem.  This is by far the most significant problem that I hear from relatives, acquaintances, and the public in general.  If nonpsychiatric medical diagnoses are supposed to be highly accurate based on biological tests – a substantial number of people never actually experience that.

On the fuzzy diagnosis in psychiatry critique, a common theme here is to go after the bereavement exclusion and suggest that normal bereavement will be treated like depression.  I have an extensive response to this when it was posted in a newspaper article and invite any interested reader to look at the previous blog post and the fact that this approach to grieving patients who come to the attention of psychiatrists has been written about for over 30 years (see last 5 paragraphs at link).  Practically every point in this section of the editorial can be disputed but the point of the article is not a scientific review, it is basically a selection of comments to support a specific viewpoint.

To Dr. Frances credit he references an excellent meta-analysis by Leucht, et al on how the results of psychiatric treatment are as good or better than the results of other medical specialties.  He is silent on how that occurs if psychiatric diagnosis is so unreliable and inaccurate.  How is it possible to get results that good compared with other specialties?  Maybe it is because as I have just suggested, the “special problems” in psychiatric diagnosis are really general problems that are shared by all medical specialists?

The criticism is less focused in the final paragraphs with some commentary on style points about the DSM political process, the issue of conflict of interest focused on publishing profits, and the idea that the APA should submit the DSM to oversight by a broad coalition of “50 mental health associations”.  Let me take the last point first.  There are a number of other diagnostic approaches and manuals that have been completed by coalitions of several other mental health organizations.  With the number of different approaches, I would encourage any organization to publish their own approach to the diagnosis of mental disorders.  Contrary to the rhetoric suggesting that there is a DSM monopoly, nothing could be further from the truth.  The entire text of the World Health Organization’s (WHO) ICD-10 is available free online.  The Mental and Behavioral Disorders section of the ICD-10 gives detailed descriptions of each disorder.  The detailed research criteria for ICD-10 can be purchased for about ¼ the cost of a DSM5.  It seems to me that there is a marketplace of ideas and plenty of competition.  If I was not a psychiatrist with an interest in reading about developments in my field, I would not be compelled to purchase a DSM5.  I would probably take a few courses in the changes to DSM-IV and stick with that for a while.

On the issue of submitting the DSM5 to outside groups there are several compelling reasons why that would not be a good idea for most psychiatrists.  Some critiques have suggested that psychiatry should be open to forced collaboration by others based on previous relationships.  Over the span of my career, I have noted that there is often an adversarial approach by other organizations rather than an affiliative one.  And why wouldn’t there be?  This is the United States and everyone here is familiar with the competitive and politicized atmosphere.  It seems like that has been left out of the equation when charges of “conflict of interest” are leveled at the APA in the area of publishing a DSM.  A recent critique of the DSM5 also suggested broader collaboration with social scientists and I critique that article here.  The political slant of all of these articles is that the APA needs the input of others to improve descriptive psychiatry.  Including that in an article that has a basic thesis that: “We will be stuck with descriptive psychiatry for the forseeable future.” (line 27-28) being a negative is inconsistent.  If anything Dr. Frances seems to be suggesting that we should be moving more to the biomedical side and  distancing ourselves from the social scientists.  The bottom line here is that the DSM5 is a diagnostic guideline for psychiatrists to use in clinical practice.  It is not synonymous with a psychiatric diagnosis and it is used at some level by psychiatrists to understand mental disorders.  It is not designed for anyone to read and act like a psychiatrist and it has nothing to do with people who do not have psychiatric problems.  It is not a “Bible” like the New York Times suggests.  It is a tool for psychiatrists and if you are not a psychiatrist there may be no reason for you to buy it or even think that it is relevant to you.

On the issue of Dr. Frances serial DSM5 critiques - this seems like a war of attrition to me.  Dr. Frances has an infinite number of venues that are quite willing to publish his very finite and repetitive criticisms of the DSM5 and the associated process.  Outside of myself – there appears to be nobody else including the American Psychiatric Association who is willing to offer the obvious counterpoints.  He has more time on his hands and many more connections than I do.  So in terms of sheer volume I guess this is a Pyrrhic victory of sorts.  I will have to be content with expressing the opinion of a psychiatrist who practices real psychiatry,  making diagnoses and helping people every day and knowing that my results are on par with anybody else in medicine and that there is nothing random about it.

George Dawson, MD, DFAPA

Myths in the Huffington Post

Let me start out by saying that I have a low opinion of the Huffington Post largely because of its rhetorical approach to psychiatry.  Tales about the pharmaceutical company corruption of psychiatry, ongoing articles about the myth of mental illness, references to very poorly done research that supposedly discredits psychiatry, the idea that the DSM is either a manual for everyman instead of clinical psychiatrists or a book written to manipulate the general public - the Huffington Post has it all and then some.  Interestingly, the Huffington Post lists these postings under "Science" when it is clear that nobody there seems to know the first thing about science or how it differs from personal opinion.  From what I have seen, listing yourself as an authority on science apparently makes it so on the Internet.  "Rhetoric/Politics" would be a much more accurate heading.

Enter Allen Frances commenting in blog form.  I have already responded to one of the Dr. Frances editorials that seem to pop up everywhere.  I find the whole process of taking a scientific debate within a professional society into a public forum somewhat appalling.  In this case, the rhetorical device of applying a decision made about an entirely different process - withdrawing a paper that the author believes was incorrectly done due to a methodological error ( one that is common to much psychosocial research) to the DSM process seems rhetorical to me.  That occurs after the process has been thoroughly politicized in the media.

The arguments themselves are either red herring or they make it seem like the very public decrying of the DSM process has shamed the APA into not declaring grief and psychosis risk to be diagnoses.  The public will never know what the APA process would have decided on these issues and of course every critic wants to take credit for exposing the APA as a group of money grubbing scoundrels whose only mission in life is to appease Big Pharma or generate huge revenue for the organization.

I wish I could count on the public to be as skeptical of these opinions as they are of other political opinions.  Unfortunately after 25 years of practice, I can say with certainty that only a few people know what a psychiatrist is or how they are trained.  Today there is more misinformation than ever about psychiatry via the Internet.

As a reminder, the DSM is for clinical psychiatrists and psychiatric research.  Reading criteria without the associated training is not the same thing as making a diagnosis.  There are many nonpsychiatric mental health professionals and many nonpsychiatric physicians.  In fact, the bulk of psychotropic medications in this country are prescribed by nonpsychiatric physicians.  Access to psychiatrists is tightly controlled by managed care companies and state governments. It is difficult to see a psychiatrist initially and over time.  These same managed care organizations control who is admitted to and discharged from inpatient psychiatric units and the type of care provided there.

The idea that the APA is an omnipotent organization with the power to manipulate and control the provision of mental health care through out the USA is a myth of massive proportions.  The idea that the DSM is a potential tool for that manipulation is another.

You can probably read about that first on the Huffington Post.

George Dawson, MD, DFAPA

DSM5 - NEJM Commentaries

I highly recommend the two commentaries in the New England Journal of Medicine this week.  The first was written by McHugh and Slavney and the second by  Friedman.  Like Allen Frances they are experienced psychiatrists and researchers and they are likely to have unique insights.  I may have missed it, but I am not aware of any of these authors using the popular press to make typical political remarks about the DSM.  Those remarks can be seen on an almost weekly basis in any major American newspaper.

McHugh and Slavney focus interestingly enough is the issue of comprehensive diagnosis and opposed to checklist diagnoses.  It reminded me immediately that the public really does not have the historical context of the DSM or how it is used.  It also reminded me of the corrosive effect that managed care and the government has had on psychiatric practice with the use of "templates" to meet coding and billing criteria in the shortest amount of time.   Finally it reminded me of the bizarre situation where we have managed care companies and governments combining to validate the concept of a checklist as a psychiatric diagnosis and court testimony by experts suggesting that it is negligent to not use a checklist in the diagnostic process.

McHugh and Slavney summed up in the following three sentences: “Checklist diagnoses cost less in time and money but fail woefully to correspond with diagnoses derived from comprehensive assessments. They deprive psychiatrists of the sense that they know their patients thoroughly. Moreover, a diagnostic category based on checklists can be promoted by industries or persons seeking to profit from marketing its recognition; indeed, pharmaceutical companies have notoriously promoted several DSM diagnoses in the categories of anxiety and depression.” (p. 1854)

In my home state, the PHQ-9 is mandated by the state of Minnesota to screen all primary care patients being treated for depression and follow their progress despite the fact that this was not the intended purpose of this scale and it is not validated as an outcome measure.  The PHQ-9  is copyrighted by Pfizer pharmaceuticals.

The authors go on to talk about the severe limitations of this approach but at some point they seem to have eliminated the psychiatrist from the equation. I would have concerns if psychiatrists were only taught checklist diagnoses and thought that was the best approach, but I really have never seen that. Politicians, managed care companies, and bureaucrats from both are all enamored with checklists but not psychiatrists. They also talk about the issue of causality and how that could add some additional perspective. They give examples of diagnoses clustered by biological, personality, life encounter, and psychological perspectives. Despite its purported atheoretical basis, the DSM comments on many if not all of these etiologies.

Friedman's essay is focused only on the issue of grief and whether or not DSM5 would allow clinicians to characterize bereavement as a depressive disorder. That is currently prevented by a bereavement exclusion and DSM-IV and apparently there was some discussion of removing it. He discusses the consideration that some bereavement is complicated such as in the situation of a bereaved person with a prior episode of major depression and whether the rates of undertreatment in primary care may place those people at risk of no treatment.

There can be no doubt that reducing a psychiatric diagnosis to a checklist loses a lot of information and probably does not produce the same diagnoses. There is also no doubt that the great majority of grieving persons will recover on their own without any mental health intervention. Both essays seem to minimize the role of psychiatrists who should after all be trained experts in comprehensive diagnoses (the kind without checklists). They should be able to come up with a diagnostic and treatment formulation that is independent of the DSM checklists. They should also be trained in the phenomenology of grief and the psychiatric studies of grief and realize that it is not a psychiatric disorder.  If they were fortunate enough to be trained in Interpersonal Psychotherapy they know the therapeutic goals and treatment strategies of grief counseling and they probably know good resources for the patient.

The critiques by all three authors are legitimate but they are also strong statements for continued comprehensive training of psychiatrists. There really should be no psychiatrist out there using a DSM as a "field guide" for prescribing therapy of any sort based on a checklist diagnosis. Primary care physicians in some states and health plans have been mandated to produce checklist diagnoses.  The public should not accept the idea that a checklist diagnosis is the same as a comprehensive diagnostic interview by psychiatrist.

That is the real issue - not whether or not there is a new DSM.

George Dawson, MD DFAPA

McHugh PR, Slavney PR. Mental illness--comprehensive evaluation or checklist?

N Engl J Med. 2012 May 17;366(20):1853-5.

http://www.nejm.org/doi/full/10.1056/NEJMp1202555?query=TOC 

Friedman RA. Grief, depression, and the DSM-5. N Engl J Med. 2012 May

17;366(20):1855-7.

http://www.nejm.org/doi/full/10.1056/NEJMp1201794?query=TOC

Why Allen Frances has it wrong

Allen Frances has been a public critic of the DSM process and as an expert he frequently gets his opinions out in the media.  Today he has an op-ed piece on the New York Times that is a more general version of a more detailed post on the Health Care blog.  His main contention is the stakeholder argument and that is that there are too many stakeholders both public and professional to allow the American Psychiatric Association to maintain its "monopoly" on psychiatric diagnosis.  I will attempt to deconstruct his argument.

He discusses the earlier DSM versions as revolutionizing the field and the associated neuroscience but then suggests that diagnostic proliferation has become a central problem and the only solution is political arbitration.  What about the issue of diagnostic proliferation?  The number of diagnostic entities per DSM are listed below:

DSM-I, 268 entities

DSM-II, 339 entities 

DSM-III, 322 entities

DSM IIIR, 312 entities

DSM-IV, 374 entities

DSM-V,  370 - 400 entities (depending on final form)

In terms of the total diagnostic entities, I have not seen any stories in the media pointing out that the total number of diagnoses may end being less than DSM-IV.  I have also not seen any discussion of major diagnoses where that is clearly true, such as the elimination of schizophrenia subtypes.   Other issues on diagnostic proliferation that are not discussed are the other required diagnostic system in medicine - the International Classification of Diseases 9th Revision or ICD-9.   The recent modification the ICD-10 has undergone a revision and the total number of diagnoses has increased from 14,000 to 68,000 diagnosis codes.  A fourfold increase.  The number of potential codes for a fractured kneecap has gone from 2 to 480 or more than the total potential codes in DSM5. 

I have also not seen any discussion of the role of psychiatrists in making a psychiatric diagnosis.  Psychiatric diagnosis does not depend on looking up a diagnosis in a catalog of symptoms.  It involves being trained in psychopathology and knowing the patterns of these illnesses.  The patterns of psychotic disorders and the other main diagnostic groupings have basically been unchanged across DSMs.  Psychiatrists make clinical diagnoses based on these major groupings and not the total number of diagnostic entities.

Further evidence that the total number of diagnostic categories is unlikely to have any impact on the number of people diagnosed with mental illness in any given year comes from the distribution of diagnostic codes in an outpatient setting. For 2006-2007, there were approximately 58 million ambulatory care visits for mental disorders. 92% of those visits were for 10 major diagnostic categories that have not changed in recent DSM revisions. It is not likely that new diagnostic categories will significantly impact the remaining 8% or 4.8 million visits per year.

In a study more specific to psychiatry, the number of psychiatric ICD-10 codes used in Danish Psychiatric Central Registry.  The data  represented 1,260,097 diagnoses from 1,041,589 discharges of 653,754 patients from in- and outpatient treatment episodes.  Forty nine of the diagnostic codes accounted for 75% of all the diagnoses (Munk-Jørgensen, et al). 

The "medicalization of normality" is another argument.  The media routinely runs stories about the percentage of the population that is "mentally ill" based on DSM diagnoses.  One of the common stories is the estimate that as many as 50% of the population has a DSM diagnosis over the course of the year.  There is never a critical look at that statistic.  The first dimension is whether any percentage should be too high or too low.  For example, would anyone be surprised to learn that 100% of the population has a medical diagnosis in the previous year?  With a high prevalence of gastroenteritis and respiratory infections - probably not.  The second dimension speaks directly to the issue of threshold for an illness.  One of the key papers in this area shows that although the one year prevalence using DSM criteria may be high, limiting the diagnoses to severe disorders reduces the prevalence to 8%.

The use of high prevalence numbers for mental illness based on DSM diagnoses also ignores the extensive Epidemiological Catchment Area (ECA) work that estimated lifetime prevalence.  Readers are generally not told that the methods used include addictive disorders and neurological disorders that cause cognitive impairment.  Would anyone doubt that 32% of adults would report a psychiatric disorder that included an addiction or cognitive impairment at any point in their lifetime?

Similarly there has been the repeated criticism that psychiatrists were going to start treating grief like clinical depression.  I have never seen that approach anywhere in my career spanning psychopathology seminars, journal articles, and continuing education courses.  Any psychiatrist with a clue knows the difference between grief and depression and at some point they have probably been tested on that difference.  What psychiatrists know that is not public knowledge is that a small number of grieving people actually develop a depression that is indistinguishable from clinical depression and it may have to be treated that way.  Knowing the difference is part of psychiatric expertise and you really cannot write it down as sentences in a manual.  In fact, it is a grave  mistake to equate a manual of diagnostic criteria with the clinical expertise and methods of psychiatry.

Dr. Frances correctly points out that the other common media theory that DSM diagnoses are driven by the pharmaceutical industry is a myth.  He continues on to suggest that the public and other mental health professionals somehow have a stake in the DSM and that organized psychiatry has frozen them out.  He concludes: “Psychiatric diagnosis is too important to be left exclusively in the hands of psychiatrists.”  I don’t understand how the specialty who invented the technology, who is trained and tested on it, and who is focused on a comprehensive view of psychopathology that extends beyond it should somehow give way to political considerations.  As he points out – there are always political considerations – even in science.  I would suggest that there is no such thing as “independent scientific review” of anything that psychiatry does.  There are many ways to address issues of professional bias in terms of including a diagnosis or not.

The arguments against the DSM and psychiatric influence vary across the usual spectrum of there being no such thing as a psychiatric diagnosis to there are too many diagnoses to the fact that psychiatric diagnoses are nonspecific.  There is no practical way to incorporate that spectrum into a diagnostic manual that is designed for psychiatrists to make clinical diagnoses and do research.  The single most important fact that is left out of these debates is that psychiatrists are effective in treating serious mental illness and they are undoubtedly more effective now than they have been in the past.  That is the only reason we need a DSM and that is why it stays squarely in psychiatry.

George Dawson, MD, DFAPA  


Frances A.  Diagnosing the DSM.  New York Times May 11, 2012.

Frances A.  DSM5 begins its belated and necessary retreat.  Health Care Blog May 10, 2012.

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Schappert SM, Rechtsteiner EA. Ambulatory medical care utilization estimates for 2007. National Center for Health Statistics. Vital Health Stat 13(169). 2011. (see Table 7.)