DSM-6? Don't Get Your Hopes up.....

 

I just spent a while reading all the papers in the American Journal of Psychiatry about the future DSM (1-5).  As you might expect many people have many things to say and that is as true inside as outside the field.  We are on the cusp of another epoch of DSM articles in the popular press that will predictably vary from inadequate to horrific. Those articles will claim that the DSM is published as a source of revenue for the American Psychiatric Association (APA), as a way for pharmaceutical companies to make money, and as a “Bible” for psychiatrists.  There will be philosophical musings tangentially related to the field but extremely critical.  There will be the usual antipsychiatry screeds about how it is unscientific, how there are better systems out there, and how the diagnoses are mere labels that mean nothing. Most of those opinions will be written by people who have never practiced psychiatry or been treated for a mental illness.  It seems that just about anybody believes that they are an expert in psychiatry.

For those of us familiar with the field - our backgrounds are more uniform. A significant number of people are like me – undergrad science majors who are always interested in biological science and medicine. We practiced in acute care settings and saw people with significant medical comorbidity.  We made plenty of medical and neurological diagnoses that nobody else made and were a resource for that kind of referral.  We knew early on that many of the diagnoses listed in the DSM were questionable and we never used them. It turns out we are the last people the DSM is designed for and after reviewing recent opinion pieces I will tell you why and how it can be corrected.

The lead paper by Oquendo, et al (1) briefly reviews common cited problems with the DSM and possible remedies.  The first criticism is that it is atheoretical. That is less of a problem than described.  Any reader of the DSM sees immediately that despite the stated atheoretical stance there are clear stated etiologies for DSM listed diagnoses. To keep it simple, I refer any reader to the table Diagnoses associated with substance class (p. 482).  That table contains 127 diagnoses associated with specific substances.  There are similarly many diagnoses that identify a psychosocial factor as being involved in the etiology.  Categories versus spectrums are listed as problem 2, despite the fact there probably are no spectrums (from the genetic side) and all polygenic medical conditions (hypertension and diabetes mellitus for example) have the same limitations. There are 4 additional uninteresting points and proposed solutions.  One of the subcommittees is focused on the Dahlgren-Whitehead framework for social determinants of health.  At the same time another committee is looking at instruments to assure a more comprehensive sociocultural assessment.  It made me wonder whether anyone on the committee had ever read a current comprehensive psychiatric assessment.  Every psychiatrist should have concerns about more checklists.

The second paper by Cuthbert, et al (2) was about biomarkers and biological factors. The discussion was long on biomarkers and short on biology.  To neuropsychiatrists this section of the DSM has always been a disappointment. As an example, the section with the most biology – neurocognitive disorders has surprisingly little discussion of associated medical features (like a gross characterization of EEG in delirium) or a discussion of neuropathology without any additional discussion of what that looks like clinically.   The Oquendo committee (1) has proposed changing the name of the DSM to the Diagnostic and Scientific Manual because it is no longer used to collect statistics.  If that occurs, they need to put a lot more science into it, and this is the area for it. 

I have proposed a separate DSM for psychiatrists in the past but a separate volume on the current science of psychiatry would be as useful. I am talking about more than just a review of unproven research, but how the science-based psychiatrist translates what we know so far into clinical practice.  I would start with a rewrite of the section on Neurocognitive Disorders and all the important variations before worrying about plasma biomarkers and whether they are FDA approved. There are volumes written on this subject that have been lost on the DSM.  To cite a few examples – should a psychiatrist be able to recognize presentations of encephalitis, meningitis, and the various presentations of vascular dementia from their own assessment and available imaging and lab studies?  Should a psychiatrist be able to diagnose various forms of aphasia and do the indicated evaluation? Of course, they should – and it is all part of the rule out criteria for psychiatric disorders. It is not enough to leave the medicine and neurology of psychiatry to somebody else.  But very little is mentioned in the DSM except the rule out conditions: “the disturbance is (or is not) attributable to the physiological effects of a substance or another medical condition (or mental disorder).”  That is too vague for psychiatrists.  

The Structure and Dimensions Committee (3) is charged with coming up with the most clinically useful structure of the future DSM.  That involves incorporating recent research.  They have produced a lengthy table summarizing the total categories, named categories and prevailing frameworks and theories used for all the DSM starting with the first one. That number goes from 4 to 22 categories in the DSM 5-TR.  There is usually criticism about diagnostic proliferation – but not much about category proliferation.  When I encounter these numbers – I remind myself that we started with a unitary psychosis model in the 19^th century.  By 1918 (6) the situation not much better with the major diagnostic categories being psychosis or not psychosis. It could be argued that early diagnostic and classification efforts failed to recognize or include mental disorders that had been observed since ancient times rather than lower numbers being more ideal.

The fourth paper (4) is focused on Quality of Life (QOL) as an essential part of psychiatric diagnoses. They establish premises based on the often-quoted literature on disability associated with psychiatric diagnoses.  They describe a bidirectional relationship:  “… symptoms of a mental illness can impair the individual’s functioning in daily life, and poor functioning can in turn lead to or exacerbate the symptoms of a mental illness.”  The paper has two definitions of QOL.  The author’s definition is “a person’s subjective perception of their emotional, psychological, and social well-being.”  The paper also contains the World Health Organization (WHO) definition of QOL “incorporates how an individual feels about their emotional, social, and physical well-being, which can affect and be affected by their mental health condition(s).”  WHO further defines QOL as “one’s perceptions of their position in life, contextualized by the culture and value systems in which they live, in relation to their expectations, goals, and standards.”  There is a related discussion on the Global Assessment of Functioning (GAF) from previous DSMs.  QOL metrics were decided to be subjective rather than clinical ranking like the GAF.  The GAF was also thought to conflate symptoms of mental illness with functioning even though there is a clear relationship. 

The authors discuss the World Health Organization Disability Assessment Schedule 2.0) (WHODAS-2.0) and it’s use to rate psychiatric disability. It is a 36-item, 100-point self-administered, 6-dimension rating scale.  Administration and scoring in full clinical schedules was considered a limiting factor, but clinically the question is what happens with more identified problems?  Does the treatment plan expand proportionally?  Will psychiatrists be expected to either treat directly or develop referral sources for all the disabilities identified as communication, mobility, self-care, interpersonal, life and societal activities. Additional briefer QOL instruments are discussed as well as brief interventions.

A critical concept that was not mentioned was the patient’s baseline function. With every patient I saw, I had a subjective (and often other informant) description of their baseline level occupational, academic, and interpersonal functioning.  In some case it involved activities of daily living (ADLs) and instrumental activities of daily living (IADLS).  On inpatient units those ADLs were often documented by occupational therapists.  In my outpatient Alzheimer’s Disease and Memory Disorder clinic – every new patient had their ADLs documented by the RN staffing the clinic.  It required hours of work per day that were not reimbursed.  My clinic was eventually shut down because of that unreimbursed work and my refusal to do the work myself for free. The additional cost and time for these assessments is a reality factor in the modern rationed health care system.

The fifth paper is entitled: “The Future of DSM: A Strategic Vision for Incorporating Socioeconomic, Cultural, and Environmental Determinants and Intersectionality.”  The definition of intersectionality is “a framework for understanding how various social and political identities—such as race, gender, class, sexuality, and ability—overlap and intersect to create unique combinations of privilege and systemic discrimination.”  I have a problem with the use of a vague term that is used rhetorically being implemented in a DSM.  The DSM is a target of rhetoric and putting rhetoric in the manual is likely to amplify its role as a target.  I have also reviewed ample evidence that the major journal of the APA – was unable to separate rhetoric from reality in the case of clear historical evidence about racial discrimination.  This highlights the need for clear definitions and avoiding political rhetoric in any rethinking of this manual.  It also highlights the need for clear evidence rather than rhetoric and that commentaries – even in the flagship journal of the American Psychiatric Association cannot be depended upon for that evidence.

Intersectionality is unnecessary to get at what the authors hope to accomplish.  Cross cultural psychiatric evaluations are the case in point. They involve an assessment of cultural differences and how the culture affects disease definitions and presentations, the sick role in that culture, and how demographic factors affect how a person is advantaged or disadvantaged in their original or adopted culture. The authors suggest it is necessary to promote various public health prevention strategies and promote health care equity.  As far as I can tell, health care equity in the US is strictly in the purview of politics and in one year a massive amount has been destroyed by the Trump administration.  Political features should be avoided as much as rhetorical features in a DSM, especially given the abysmal track record of physician medical organizations in politics.

The authors define socioeconomic, cultural, and environmental determinants of health (SCE-DoH) as the key focus (along with intersectionality). These determinants are all well known to any psychiatrist who has recorded a social history for a detailed assessment and that should include all of us.  They conceptualize them as modifiable or non-modifiable risk factors and how they may be relevant for prevention strategies.  Much of the prevention is outside the scope of psychiatric practice and advocacy by professional organizations has questionable impacts.  They also use the Dahlgren-Whitehead model of main health determinants and cover suggestions of screening patient populations for these variables.  They conclude that the next DSM should include recommendations to use multiple “vetted instruments” to make these SCE-DoH assessments.  They give an example of how this assessment can be built into routine clinical care.  Interestingly, the psychiatric assessment is not included in the “routine diagnostic workflow” (see figure 2).  Looking at the strategy 2 where the SCE-DoH is used to determine “management as usual” versus “enhanced case management” – I made that determination myself for 40 years. For the last 25 years that “enhanced case management” was not available for most people needing it. That tells me that the suggested assessment is already being done by some people and the necessary resources are not there.  I found myself documenting that fact in too many cases.

The Committee realizes that they cannot create an additional burden on clinicians who already have unrealistic demands and provide far too much work for free in rationed environments.  That translates to less time to do comprehensive assessments – not more.  

Even though these are very preliminary statements about the future DSM – I am not very hopeful at this point.  The commentaries so far seem directed at criticisms from outside of the field rather than what psychiatrists need.  Apart from the criticism I have offered so far what is noticeable:

1:  The lack of commentary on medical and neurological diagnoses – in any psychiatric classification it is either explicit (or implicit) that what are considered the current psychiatric diagnoses are not caused by a substance or another medical diagnosis.  The non-DSM diagnostic systems are generally just focused on the listed symptoms of these disorders and there is no provision for other medical conditions.  It is also not explicit enough in medical training. At some level this is explained away and needing to utilize whatever resources are available.  That is not enough.  The DSM should have a section of diseases by system that need to be diagnosed if they are present and at least a reference to how that should be done.  There is not nearly enough information on what medical diagnoses psychiatrists make.  This is also an important feature for resident education since it would suggest how much clinical medicine and neurology residents need to be exposed to and whether they are seeing relevant cases.

2:   Philosophical criticisms while minimizing biology and history –  in several of the papers the authors talk about “natural kinds” and “carving nature at the joints”.  This is philosophy speak that has been used to obfuscate the field. The first time I encountered these arguments they struck me as obvious nonsense.  That was first suggested by Thomas Sydenham when he made this statement in about 1640:

“In writing the history of a disease, every philosophical hypothesis whatsoever, that has previously occupied the mind of the author, should lie in abeyance. This being done, the clear and natural phenomena of the disease should be noted — these, and these only…” (7) 

DeGowin and DeGowin (8) summed up the process over the next three centuries:

"For several thousand years physicians have recorded observations and studies about their patients.  In the accumulating facts they have recognized patterns of disordered bodily functions and structures as well as forms of mental aberration.  When such categories were sufficiently distinctive, they were termed diseases and given specific names.”

It seems that the conceptual clarity here requires no reference to naturalism or essentialism.  It only requires empiricism and a determination of sufficiently distinctive.  In my long and intensive career – the only place I have encountered these philosophical arguments was in a literature that was generally critical of psychiatry.  In the process it also requires psychiatrists to suspend the idea that empirical adequacy is not all that is required, but also all that we were taught. 

Conceptual expansionism or semantic drift has been used to criticize the DSM and psychiatry and that needs to be called out wherever it happens.  By that I mean a concept that is developed within one academic silo that is suddenly applied without precedent or a clear basis to psychiatry.  On this blog I have criticized several of these applications including epistemic and hermeneutical injustice.  Although none of the Am J Psychiatry papers used the term, I did encounter folk psychology now being applied to criticize the DSM (9) in a mailing.  That is a concept I was familiar with from Andy Clark’s work (10).  If you are not familiar with the concept a generally accepted definition would be:  “The everyday ability to predict and explain the behavior of ourselves and others by attributing mental states—such as beliefs, desires, intentions, and fears.”  In other words – you see somebody doing something and come up with a theory of why they are doing it.  I have written about it on this blog as a reason why many people seem confident in their knowledge of psychiatry and psychology even though they have never been trained in either. There are several theories of how a folk psychology theory can apply, but the original debate centered on how the ascribed beliefs, desires, intentions, etc. had no neural equivalent and therefore that at some point these mental states would be replaced by more scientific terms. In other word suggesting that the DSM is folk psychology is basically saying the signs and symptoms used as descriptors have no brain equivalent and therefore it is an invalid classification. This argument is essentially the same argument that there is an explanatory gap between what most people consider consciousness to be and the neural substrates that causes it.  Consciousness is approximately represented in neural substrate and the same thing can be said for mental disorder symptoms.      

3:  The continued lack of focus on what might be useful to psychiatrists - 

When I think about a DSM that might be useful to psychiatrists or at least the kind of psychiatrists I am used to working with – there needs to be more than the usual slicing and dicing of diagnostic criteria.  Adding more work with more rating scales is also a disappointment.  A manual breaking down the current work with examples and a suggestion of the potential exhaustive data points might be. For example, pointing out that the typical phenomenology of a disorder should be adequately represented in the history of the present illness.  That obviously includes any precipitating factors irrespective of what they might be – biological or sociocultural. The next section should include a discussion of the past psychiatric and medical histories as well as comorbid conditions.  Psychiatrists should be expected to know relevant medical diagnoses, how medical comorbidity affects psychiatric treatment, and medical causes of psychiatric presentations.  The usual disclaimer about medical conditions is as inadequate as a disclaimer about sociocultural aspects of care.  The new DSM should not be a mere collection of psychosocial determinants completely devoid of medicine.

A more formal formulation section should be there.  In the DSM-5 for example it is referred to as a “concise summery of the social, psychological, and biological factors that may have contributed to developing a given mental disorder.”  (p. 19).  There are multiple ways to write a formulation (behavioral, psychodynamic, neuropsychiatric, and others) and they should all be discussed in the DSM.

4:  A theory section on the biology of psychiatric diagnoses – why they are complex and how that complexity should be approached.  There are experts in the field who can comment on how polygenes produce quantitative diagnoses that can blend imperceptibility into the normative states.  Some of those same experts can discuss the statistical methods used to try to improve classifications and how that works clinically.  There should be a comparison with other commonly described quantitative disorders like hypertension and diabetes mellitus Type 2.  The classification system of rheumatology could be discussed as a direct comparison to the DSM.

I have written about the problem with the term transdiagnostic. I do not think it adds any specificity to interventions.  In psychiatry what is considered a transdiagnostic symptom can also conceal a potential primary problem. One of the most common scenarios I encountered in practice was longstanding insomnia prior to the onset of depression. In the transdiagnostic scenario, insomnia could be considered just that or a symptom of another disorder rather than a primary sleep disorder. All these issues including categorical versus dimensional diagnoses should be covered in this theory section written by our experts.  There are plenty of reasons not to blindly accept the transdiagnostic jargon as being that relevant.    

Psychometrics can be discussed in the theory section.  We have all heard and read about reliability of diagnoses for decades and a lack of validity. Reliability statistics are available for a range of DSM categories and that could be included as a single graphic with a brief discussion.  The discussion of validity needs to be more extensive and nuanced rather than just dismissed.  Study groups from DSM-5 were working on 11 validity indicators.  It is time to see them on graphics like what can be constructed for reliability. The data should be included where it exists.

5:  A genetics section:  Genetics and the associated molecular biology is the future of medicine and psychiatry. A summary of that data should be available in the DSM as well as the clear importance of this information.  At the biological level, the discussion should be clearly focused on changes in brain systems associated with disorders and the problem of many genes affecting these systems.   

6:  Definition/Threshold of a disorder:

There is always criticism about the dysfunction threshold for making a diagnostic assessment.  There is never much discussion about why it is necessary or why there are consensus diagnoses.  Even a superficial look at other specialties that treat polygenic heterogeneous entities invites comparison.  Rheumatology is a case in point:   

“Rheumatologists face unique challenges in discriminating between rheumatologic and non-rheumatologic disorders with similar manifestations, and in discriminating among rheumatologic disorders with shared features.  The majority of rheumatic diseases are multisystem disorders with poorly understood etiology; they tend to be heterogeneous in their presentation, course, and outcome, and do not have a single clinical, laboratory, pathological, or radiological feature that could serve as a “gold standard” in support of diagnosis and/or classification.”

A recent review of polymyalgia rheumatica (PMR) in the NEJM (11) looked at diagnostic algorithms for both acute PMR and treatment.  The introduction involved the statement:  “The diagnosis of polymyalgia rheumatica is made on the basis of clinical grounds by combining characteristic signs and symptoms with laboratory findings and ruling out common mimickers such as late-onset gout and pseudogout and others.”  (p. 1099).  I counted 23 conditions in the differential diagnosis.  One of the criteria for the diagnosis is “functional impairment”.  The implication is that it is due to morning stiffness or possible pain but that is not specific.  There are limited reviews of how to establish diagnostic criteria for diseases and disorders that lack objective tests (12).  I think the degree of dysfunction is obviously relevant when assessing disorders that are based on purely subjective signs and symptoms.  It factors into routine clinical care of both known and unknown diagnoses. On this blog I have documented examples from numerous medical and surgical specialties.

That is my criticism after reading 5 current papers on the direction of the DSM.  I really do not want the next volume to look like what has been described so far. When I think about my final 1500-2500 word assessments that contain just about everything the authors of these papers discuss and much more – I do not want to see all that good work sacrificed because somebody wants to include more checklists or dimensions of questionable value. I have had people tell me years and in some cases decades later, that they found those assessments to be valuable and useful for future evaluation and treatment of that same person.  

If I had to capture three elements that the future DSM planning seems to miss it is that phenomenological assessments can easily contain as much or more data than checklists, that psychiatry is a medical specialty, and that like all medical specialties the field has boundaries. The current suggestions from these papers stretch those boundaries into activism, politics, and importing criticism from other academic silos rather than a restatement of what is relevant for psychiatric assessment and classification. 

That should be the priority…    

 

George Dawson, MD, DFAPA

 

 

 

References:

1:  Oquendo MA, Abi-Dargham A, Alpert JE, Benton TD, Clarke DE, Compton WM, Drexler K, Fung KP, Kas MJH, Malaspina D, O'Keefe VM, Öngür D, Wainberg ML, Yonkers KA, Yousif L, Gogtay N. Initial Strategy for the Future of DSM. Am J Psychiatry. 2026 Jan 28:appiajp20250878. doi: 10.1176/appi.ajp.20250878. Epub ahead of print. PMID: 41593833

2:   Cuthbert B, Ajilore O, Alpert JE, Clarke DE, Compton WM, Drexler K, Fung KP, Gogtay N, Kas MJH, Kumar A, Malaspina D, O'Keefe VM, Öngür D, Tamminga C, Wainberg ML, Yonkers KA, Yousif L, Abi-Dargham A, Oquendo MA. The Future of DSM: Role of Candidate Biomarkers and Biological Factors. Am J Psychiatry. 2026 Jan 28:appiajp20250877. doi: 10.1176/appi.ajp.20250877. Epub ahead of print. PMID: 41593830.

3:  Öngür D, Abi-Dargham A, Clarke DE, Compton WM, Cuthbert B, Fung KP, Gogtay N, Kas MJH, Kumar A, Malaspina D, O'Keefe VM, Oquendo MA, Wainberg ML, Yonkers KA, Yousif L, Alpert JE. The Future of DSM: A Report From the Structure and Dimensions Subcommittee. Am J Psychiatry. 2026 Jan 28:appiajp20250876. doi: 10.1176/appi.ajp.20250876. Epub ahead of print. PMID: 41593835.

4:  Drexler K, Alpert JE, Benton TD, Fung KP, Gogtay N, Malaspina D, O'Keefe VM, Oquendo MA, Wainberg ML, Yonkers KA, Yousif L, Clarke DE. The Future of DSM: Are Functioning and Quality of Life Essential Elements of a Complete Psychiatric Diagnosis? Am J Psychiatry. 2026 Jan 28:appiajp20250874. doi: 10.1176/appi.ajp.20250874. Epub ahead of print. PMID: 41593851.

5:  Wainberg ML, Alpert JE, Benton TD, Clarke DE, Drexler K, Fung KP, Gogtay N, Malaspina D, O'Keefe VM, Oquendo MA, Yonkers KA, Yousif L. The Future of DSM: A Strategic Vision for Incorporating Socioeconomic, Cultural, and Environmental Determinants and Intersectionality. Am J Psychiatry. 2026 Jan 28:appiajp20250875. doi: 10.1176/appi.ajp.20250875. Epub ahead of print. PMID: 41593836.

6: American Medico-Psychological Association. Statistical Manual for the Use of Institutions for the Insane.  1918:  https://dn790008.ca.archive.org/0/items/statisticalmanu00assogoog/statisticalmanu00assogoog.pdf

7:  Sydenham, Thomas, 1624-1689; Greenhill, William Alexander, 1814-1894; Latham, R. G. (Robert Gordon), 1812-1888.  The works of Thomas Sydenham, M.D.  Volume 1, London. Sydenham Society.  1848-1850. P. 14  https://archive.org/details/worksofthomassyd01sydeiala/page/lv/mode/1up?q=abeyance

Translation of Medical Observations by Thomas Sydenham, London, 1669. The Preface.  Original was in Latin.

8:  DeGowin EL, DeGowin RL.  Bedside Diagnostic Examination, 3^rd ed.  New York.  Macmillan Publishing Company, Inc.  1976. P. 1.

9:  Aftab A. The Future DSM: Bold redesign, lingering blind spots.  Psychiatric Times. March 2026: 12-16.

10:  Clark A.  Microcognition: Philosophy, cognitive science, and parallel distributed processing.  Cambridge, MA.  The MIT press. 1989.   

11:  Dejaco C, Matteson EL. Polymyalgia Rheumatica. N Engl J Med. 2026 Mar 12;394(11):1097-1109. doi: 10.1056/NEJMcp2506817. PMID: 41812194.

12:  White SJ, Barker TH, Merlin T, Holland G, Sanders S, O'Mahony A, Pathirana T, Theiss R, Pollock D, Reid N, Munn Z. Methods for developing diagnostic criteria for conditions without objective tests, biomarkers, or reference standards: a scoping review. J Clin Epidemiol. 2026 Feb;190:112052. doi: 10.1016/j.jclinepi.2025.112052. Epub 2025 Nov 18. PMID: 41265667.

An MGH Case For Acute Care Psychiatrists

 

I have been a New England Journal of Medicine (NEJM) subscriber since I left medical school.  It was a recommended practice in my first year Biochemistry class by the distinguished professors in that class. We had very close contact with them in my medical school for two reasons – daily seminars where we discussed research papers in the applicable topics and their graduate students talking the same course.  It was one of the more intellectually stimulating courses in medical school.   

Over the subsequent 43 years of subscribing, I have noticed a couple of trends.  The most significant one is that psychiatry has been increasingly represented on the pages especially in the past 10-15 years. It is more likely that authors and discussants in the weekly case presentations will be psychiatrists.  You can also get updates on relevant psychiatric papers sent by email. If you scan the table of contents each week it is likely that 2 or 3 papers will be relevant to psychiatric practice – more if you are a neuropsychiatrist or medical psychiatrist.

That brings me to Case 22-2025 from the July 25, 2025 issue.  I will describe the case as briefly as possible due to copyright considerations and the fact you can read all the details in your medical library copy or access.  I want to focus on the diagnostic process and what it implies for both psychiatric diagnosis and treatment.  I also want to focus on the fact that there are acute care psychiatrists in intensely medical settings and they are very knowledgeable and take care of very tough problems that nobody else does.  That can get lost on an almost daily basis as you see provocative headlines and social media posts seeking attention by distorting what psychiatrists do and what they are capable of.

The patient is a 19-year-old woman admitted with episodic right arm and leg shaking and unusual behavior.  The symptoms developed over the 10 days prior to admission with episodic shaking and numbness of the right arm, and slowed speech. A week before admission she collapsed in public and full body shaking was observed.  In the emergency department she was noted to be drooling, confused, and had bitten her tongue.  She gradually became more alert.  In the MGH ED her exam was normal and the only remarkable lab finding was an elevated lactate.  CT and MRI of the brain were normal.  An EEG was normal.  On day 1 she had sudden onset of intense fear and dread followed by whole body shaking lasting 1-1 ½ minutes.  With the last episode she had a decreased oxygen saturation to 50%.  She was started on lorazepam and levetiracetam.  On day 2 she was started on lamotrigine. She was also seen by a psychiatrist and was noted to have extension and stiffening of the right arm, flexion and stiffening of the left arm, turning the head to the right and whole-body stiffening. The episode lasted a minute and she described feeling like “brain and mind were disconnected”. She denied hallucinations, suicidal ideation, and aggressive ideation but did not think that she could return to college.  She became more agitated, tried to run out of her room, and thought the staff were trying to kill her.  She became agitated and required physical restraint and IM olanzapine.

Additional history was remarkable for a grandfather with schizophrenia and past treatment for anxiety and depression – most recently with psychotherapy and no medication.  Following a recent discharge from another hospital and a 5-day admission she was taking levetiracetam, lamotrigine, melatonin, and folic acid. She was rehospitalized after she developed symptoms on the way home from that hospitalization.

This is a severe and acute problem that every acute care psychiatrist should be able to analyze and treat.  The patient exhibits seizure like activity, catatonia, and psychosis in the form of disorganized behavior rather than any descriptions of hallucinations or delusions.  The concern about hospital staff trying to kill her could be paranoia – but unless there is corroboration that it was present for some time – it can also be due to the significant cognitive problems of poor memory and inattentiveness. 

In the subsequent discussion and unfolding events – Judith A. Restrepo, MD – a C-L psychiatrist at MGH presents a refined approach to the problem as outlined in the graphic at the top of this post.  After describing the observed characteristics of the three syndromes on the left she looks at groups of disorders that may account for the syndromes and how common they are.  Since the emergency screening has already been done, she can rule out any associated with obvious abnormalities of brain imaging studies or lab tests.  She goes through each major category and states why a diagnosis is likely of not.  For example, in the Rare Disorders Where Psychotic Sx Are Typical she mentions acute intermittent porphyria and Creutzfeldt-Jakob disease and how they are unlikely due to the illness pattern, lack of GI sx, and a normal EEG. 

In that same category, Dr. Restrepo discusses autoimmune encephalitis as a possibility and eventually lands on that diagnosis.  In the subsequent evaluation (anti-NMDA receptor antibodies, CSF studies, abdominal ultrasound and CT) the diagnosis of anti-NMDA receptor encephalitis secondary to a malignant mixed germ cell tumor of the left ovary was noted.

The case report is useful to read in full because of the complicated post diagnostic course and description of what is known about the treatment of this condition.  I am going to focus on a couple of additional diagnostic issues and the implications for psychiatrists.

Pattern matching remains a critical aspect of all medical diagnoses and that includes psychiatry.  It is still a popular trope that psychiatric diagnosis is DSM centric and nothing could be farther from the truth. The real value of psychiatry is the training and direct observation and assessment of real problems. Reading a checklist of symptoms is essentially worthless without knowing those patterns.  The obvious examples from this case are psychosis, seizures, and catatonia and their many variations.  The wording in the case report is often stacked to cause an association to those patterns.

An obvious example is whole body shaking followed by hypoxemia and an elevated lactate level should lead to an association to generalized seizures and probably similar patients seen in the past with that condition.  Similarly, the features of catatonia should be obvious without referring to a catatonia rating scale and lead to associations to past catatonia patients diagnosed and treated. Superimposed on these diagnostic patterns should be a general pattern of how to approach very ill patients – in this case patients who have either serious psychiatric disorders or psychiatric syndromes secondary to serious medical and neurological conditions. How should a stuporous or comatose patient be examined (2)?   In this specific patient could the arm movements be decorticate or decerebrate posturing?   Could they be a movement disorder?  That should include a triage pattern of how that patient needs to be stabilized until the diagnosis is determined.

As an example – what should happen if this patient is described to you as an admitting psychiatrist?  Should they be admitted to a typical inpatient psychiatric unit?  All that I would need to hear is hypoxemia following seizure like activity and my answer would be no.  They need to be in a unit that has telemetry and critical care nursing and psychiatric units do not.

There are also patterns on the rule-in side.  Are there any features of this illness that match typical patterns of schizophrenia, bipolar disorder, or depression?  Are there any features that match acute intoxication with commonly used substances?  Is the patient medically stable enough to be treated on a psychiatric unit? 

How do we prepare acute care psychiatrists who are based in medical neuroscience?  Thomas Insel the former NIMH director had the idea of a rotating clinical neuroscience fellowship where neurology, psychiatry, and neurosurgery residents would do a 2 year fellowship before moving on their respective residencies.  That is a hard sell when you come out of it needing to do another 3 – 5 years of residency. 

I propose getting ready in medical school.  Most MS4 courses are electives and there is probably room to further modify the MS3 year.  In addition to basic general medicine and surgery I recommend the following electives: neurosurgery, neurology, endocrinology, infectious disease, renal medicine, cardiology, emergency medicine, and allergy and immunology.  Just rotating through is not enough given what I have said about the pattern matching requirement.  As many acute care cases and unusual presentations of psychiatric disorders associated with brain and medical illnesses need to be seen as possible.  Only that will get residents ready to make diagnoses like the one in this case. It helps to have an attitude and interest in treating the most severe problems in psychiatry. 

And once you are out – keep reading the journals including the NEJM.

 

George Dawson, MD, DFAPA

  

Supplementary 1:  Thought I would add a couple of supplementary comments here rather than adding them to the main post.

Psychiatry is not DSM centric:  Practically every critic of the field and by default these days every social media venue and many journals have lengthy debates about the DSM, what it does or not do, and how it affects the future of psychiatry.  The above post is a shining example of what I did in over 35 years of practice.  At no point in that 35 years did I pull the old DSM off the shelf and think: “Gee I wonder what the DSM will tell me to diagnose?”  Just today I was in a seminar where the question was: “What diagnosis should we use for psychotherapy?” and reminded that the primary use of the DSM and why it was invented – initially for statistical and census purposes and now for billing and coding.  In other words, today – you do not get paid if you don’t have a diagnostic code but that code is technically an ICD-10 code and not a DSM code.

Should that role lead to protracted debates in journals and social media.  I guess I will take the lead role is saying emphatically no.  You can take all the debates about the precision and validity of psychiatric diagnoses and watch it explode in this case report. We see real psychiatry in action.  A psychiatry where patterns of illness are recognized and critical in making a diagnosis of a life-threatening condition.

Pathology in a psychiatric case:  I did not mention that this case report contains a pathology report including photos of the gross pathology and microscopic pathology of the left ovarian mass and the malignant germ cell tumor. This is reminiscent of late 19^th/early 20^th century psychiatry looking for neuropathological autopsy correlates of severe mental illness and the famous psychiatrists involved. It was a more intellectually stimulating approach and there were results but not for the major psychiatric disorders leading to asylum care at the time namely bipolar disorder, schizophrenia, and depression/melancholia. Now that the pathology is more specific should psychiatrists be taught the pathology and the pathophysiology of these disorders?  Should they be aware of all paraneoplastic syndromes that cause psychiatric symptomatology.  Of course they should. It is more important than a DSM and unless the DSM is serious about including real patterns and pathology it will be much less relevant in the future.  We have reached a limit when it comes to parsing words about psychiatric diagnoses and need to get back to reality.    

References:   

1:  Restrepo JA, Mojtahed A, Morelli LW, Venna N, Turashvili G. Case 22-2025: A 19-Year-Old Woman with Seizure like Activity and Odd Behaviors. N Engl J Med. 2025 Jul 31;393(5):488-496. doi: 10.1056/NEJMcpc2412531. PMID: 40742263.

2:  Plum F, Posner JB.  The Diagnosis of Stupor and Coma.  FA Davis Company, Philadelphia, 1980.   

  

The Map Is Not The Territory

 

I ran into a quote this week that I must have read and forgotten from the past – because it was referenced in Bateson’s Steps to an Ecology of the Mind.  That was a book I read back in the hippie era after seeing it referenced in the Whole Earth Catalogue.  It happens at a time when I was writing about the usual philosophical rhetoric used to criticize psychiatry.  The circular logic argument I have encountered frequently by philosophers seeking to either destroy the profession or portray psychiatrists as unthinking buffoons.  That quote was “A map is not the territory” and it is attributed to Alfred Korzybski.

When I saw it – I associated immediately to the map I know the best and that is Hwy US2 running across northern Wisconsin between Minnesota and Upper Michigan.  I have travelled that road hundreds of times.  In fact, in 1988 I drove it over 200 times that year to keep a small inpatient psychiatric unit open. Maps these days are much better than they used to be.  For the old road maps to have the same scale and sufficient detail meant a large size that had to be folded and refolded to get it back into the glove compartment.  The above map is a clip from Google Maps and it can be scaled down to the individual house level and from there a street view that is regularly updated.

Thinking about old maps and new maps it is easy to see Korzybski’s argument. Driving US 2 late at night it is common to encounter characteristics of the territory that are not listed or even included in your GPS updates. The territory at night is much different than the territory during the day.  A major difference is deer on the highway.  There are the occasional deer crossing signs but I have suddenly found myself driving among a herd of 30 or 40 deer running next to my car and alongside the road.  The Google camera cars fail to update the video information fast enough to account for social and cultural changes that happen in the small towns along the way.  Am I going to encounter a large influx of out-of-staters for the Blueberry Festival in Iron River or the Strawberry Festival in Bayfield?  Is that small general store still there or is it finally gone? Is the posted or suggested speed limit accurate or do I have to correct for the weather?  

In the era of climate change even modern maps have uncertainty.  Highway 2 has been washed out and under water – both events that have never happened at any other point in my lifetime.  Using modern GPS guidance – I ended up on what appeared to be a dirt wagon trail that eventually got me back to Minnesota.  Every inch of that terrain looked like it had been seen by very few people in the last 50 years and no Google camera cars.  Most people unconsciously adapt to the terrain on the drive home – that sunken manhole cover or pothole to avoid.  We automatically adjust to the hazards even though they are not indicated on any map.  

Korzybski’s argument is basically twofold. First – no matter how far you drill down with a map – even a much-detailed map you will not find what you are experiencing – what your perceptions tell you is there. The map after all is an abstraction by someone and that is not a perfect representation of geography but also not your reality.  From consciousness science - your reality or experience of it is not my reality.   From information theory – the human brain is acquiring much more information going forward than you can get from one derived across a series of finite dimensions and time.  Second – this has clear implications for the ideas of subjectivity and objectivity.  In medicine we construct clinical trials – with exclusion and inclusion criteria that eliminate large real populations and at this point cannot account for the heterogeneity in the remaining research subjects. That does not preclude progress but it should introduce humility into the eventual results. No matter how broad or narrow those selection criteria are – they are only an approximation of the real population who will be treated.

Lest these connections be seen as speculative – here is what map makers and geographers have to say about the situation.  Basic geographic data is a space-time location. In addition, there is other relational data that contextualizes a location.  Data and relationships are discussed in terms of model and how the model is a simplified representation of reality but not reality itself.  A good example was John Snow’s map of cholera during the 1854 epidemic in London and how he used that to determine the source and isolate it. Cartographers are aware of these relational loops to space-time location as well as the limitations that are due to the large number of contextual features.  The map cannot account for them all.  

What does it say about philosophy and rhetoric applied to psychiatry?   

It says a lot about classification systems.  Much research today is preoccupied with ideal classifications.  The DSM for example is criticized for not being a perfect diagnostic system when in fact (like all medical classifications) it is a crude system with additional landmarks.  The graphic below illustrates the problem and how the assumptions made for the diagram on the left do not reflect the reality of the diagram on the right. That diagram is more complex – but not nearly as complex as the real clinical situation. After all – if the clinical situation was accurately reflected in the diagram on the left everyone with schizophrenia would be the same.  Psychiatrists would not have to concern themselves with a developmental history, a social history and life narrative, a medical history, and a family history.  They would not have to consider critical psychological events in a person’s life and putting all that together in a formulation about what is unique about that person.  The territory of that person would include supportive people and important contacts. Like the map of Highway 2 – the DSM gets us into the ballpark but it is not specific about what we will find. 

Korzybski has been described as an independent scholar.  He is credited with inventing the field general semantics.  There is a research institute founded on his ideas. There are not a lot of scholars taking his work forward.  There is an excellent online biography of Korzybski that describes the controversies associated with his writings and varying degrees of acceptance.  Interestingly he wrote about psychiatry and in his biography, there was apparently a group of psychiatrists interested in his work.  He referenced “neuropsychiatry” as a field that had generally been ignored by the rest of medicine.

 

Irrespective of the complexity and controversy of general semantics – I am still focused on the map is not the territory concept for several reasons.  First it reflects what is going on in the DSM classification system.  Second, it describes limitations of any classification system and how that abstraction differs from reality. That is probably the reason that medical diagnostic systems die hard, especially after decades or centuries of the same observations.  Is there any reason to suspect a dimensional or sub phenotyping system would be any better?  Probably not at least until very detailed observations can be made.  A classic paper (4) suggested that hundreds of true/false questions identified psychological traits and that this was an actuarial method superior to clinical judgment.  Despite that alleged superiority many of the methods suggested in that review like the Minnesota Multiphasic Inventory or MMPI have fallen out of use and are no longer used for screening purposes or making diagnoses.  Machine learning and artificial intelligence can produce these results faster and on a larger database but continue to have limited applications.   Third, it reflects expert opinion by at least one of the top theorists in the field (5).  Fourth it reflects good clinical practice that includes a formulation with additional commentary on psychopathology, associated observations and theories. 

At the minimum I hope that you find Korybski’s observation as interesting as I do.  I probably will not read his voluminous works – but I am always aware of the fact that no matter what classification system you are using it is always an abstraction with various degrees of precision.  Further it is an abstraction by one person or a group of people.  The way the DSM (and all of medicine) is structured the precision of both the diagnosis and treatment of a particular patient depends on what occurs during the encounter and the experiences and abstractions of that physician.   

George Dawson, MD, DFAPA

 

Supplementary: Doing research for this post, I encountered another quote that expresses a similar idea:  "The menu is not the meal".  Alan Watts is credited with that quote. 

References:

1:  Korzybski: A Biography (Free Online Edition) Copyright © 2014 (2011) by Bruce I. Kodish.  See chapter 30 for Korzybski’s contact with psychiatry including Harry Stack Sullivan and William Alanson White:  https://korzybskifiles.blogspot.com/2014/06/korzybski-biography-free-online-edition.html?spref=tw

2: Doerr E. General Semantics. Science. 1958 Jul 18;128(3316):156.

3: Gardener M. General Semantics. Science. 1958 Jul 18;128(3316):156.

4:  Dawes RM, Faust D, Meehl PE. Clinical versus actuarial judgment. Science. 1989 Mar 31;243(4899):1668-74

5: Kendler KS. The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria. Am J Psychiatry. 2016 Aug 1;173(8):771-80. doi: 10.1176/appi.ajp.2016.15121509. Epub 2016 May 3. PMID: 27138588.

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Even More Epistemic and Hermeneutical Injustice......

My latest foray into the philosophical was reading a paper by Bennet Knox (1) called “Exclusion of the Psychopathologized and Hermeneutical Ignorance Threaten Objectivity”. In it he argues for inclusion of persons affected by mental illnesses or at least as they are defined in the DSM into the scientific process of revising the DSM. He prefers the term psychopatholigized that he shortens to pathologized to other terms used in the philosophical literature. He makes the argument against a severely truncated form of psychiatry that he can conveniently describe as hermeneutically ignorant while characterizing a brief comment by Spitzer as hostile. His argument hinges on a concept of social objectivity that necessarily means all viewpoints of the psychiatrically involved including those who want to burn the profession down are valid and must be considered.

As I have stated before on this blog (and given examples) – this is a standard philosophical approach to criticizing psychiatry while ignoring what actually goes on in the field and how psychiatrists are trained. So, I will start there.

Let me start with the concept of “social objectivity” since the early claim by the author is:

“Further, insofar as the objectivity which psychiatry should aspire to is a kind of “social objectivity” which requires incorporation of various normative perspectives, this particular form of epistemic injustice threatens to undermine its scientific objectivity.”

I am not completely sure of how philosophers use the term normative here so I am assuming that it means – what other people approve of or endorse.  The other people here would be the pathologized.  He uses examples of the pathologized in this paper as members of the Hearing Voices Movement and the Autistic Self-Advocacy Network (ASAN).  He states that social objectivity is defined in two books by Helen Longino but does not include an operational definition.  Instead, he comments throughout the paper on how various circumstances do not meet these criteria.  He openly acknowledges that his argument is deficient:

“Although I can provide only a limited argument for embracing the social objectivity model in psychiatry here, my main goal is to show fellow proponents of social objectivity that the particular kind of hermeneutical ignorance I describe presents a significant obstacle to achieving it in psychiatry.”

I agree that the argument presented is very limited.  If that is the case, why should it be achieved in psychiatry?  Will it be theoretically useful in some way? 

His introduction to the need for social objectivity and objectivity in general in psychiatry is based on the philosophy of psychiatry.  More to the point non-empiricist philosophy. If that is considered, an empirically adequate model is all that is required.  Instead, he introduces three models that all suggest that values play a role in psychiatric diagnosis. He acknowledges that dysfunction is a value free criterion for diagnosis but then goes on to separate out a category of mental disorder that also contains judgements about dangerousness.  He lands on the DSM definition of dysfunction but explains it away as “there is reason to believe that it is impossible (and undesirable) to uncover dysfunctions in mental processes without reference to values.”  He goes on to explain how “a scientific process is more objective insofar as it engages a diverse array of points of view with different normative background assumptions in a process of “transformative criticism.”

There are multiple points of disagreement with this viewpoint starting with a basic misunderstanding of what psychiatry is and how psychiatrists work. The key element in the DSM that is ignored here are all of the qualifications for subpopulations ranging from cultural differences to gender differences that include a moving threshold for the diagnosis of disorders and recognizing that in some cultures or subcultures varying degrees of psychopathology are tolerated (or not) and that also includes a tendency to stigmatize individuals with that psychopathology. Breaking that down – psychiatry parses scientific objectivity and normative perspectives when it comes to diagnosis and treatment planning. That not only occurs in psychiatry but in all of medicine and it may actively include the outside input from philosophers on ethics committees.  Here are a couple of clear examples.

Example 1:

Bob is a 65-year-old married man admitted for hepatic encephalopathy from alcoholic cirrhosis. The Internal Medicine team requests psychiatric consultation for further diagnosis and referral.  The psychiatrist assesses the patient as improved (less delirious) and competent.  No other psychopathology is noted. He discussed treatment options for the alcohol use disorder and the patient is willing to listen.  He has never attended an AA meeting or been in treatment in the past. The family (wife and adult children) enter the room and are all adamant about taking the patient home with no treatment. They are angry and state several times “If he wants to drink himself to death it is none of your business doctor. Let him drink himself to death.”  The family and the patient are approached by social workers and the Internal medicine team over the next two days but he is discharged home with no treatment.

All of the people in this case were white 4^th or 5^th generation Americans. There are no assumed cultural differences, but they are implicit. Patients and families affected by substance use disorders have known patterns of adapting and some of them are not functional adaptations. Was an attempt at involuntary treatment needed in this case? The psychiatrist knew that hardly ever happens by local probate courts in substance use disorders unless there was an actual suicide attempt or the family supported civil commitment. Should adult protection social workers have been involved?  Referrals could have been made to county social workers who might invoke a societal level value judgment on this situation but instead dialogue was established with the family and they agreed to call if problems occurred and take referral numbers for additional assistance. They were also informed that the patient had a life threatening alcohol use disorder and severe complications (including death) could occur with any future episodes of drinking.

To the point of the article this example points out that DSM diagnosis (alcohol use disorder, delirium plus dysfunction) were the objective considerations. It also illustrates a point about social objectivity and that is that it needs to be elaborated for every individual patient, family, and culture/subculture specifically. Suggesting that physicians or psychiatrists don’t have the capacity for recognizing these exceptions and planning according is not accurate. Suggesting that the patient and family were ignored or that their opinions were not considered is also inaccurate.  The entire treatment and discharge plan was based on those opinions - even after the recommended treatment was rejected and the high level of risk was explained.

Example 2:

Tony is a 28-year-old man seen in hospital following a suicide attempt. He shot himself through the shoulder and is on the trauma surgery service. When interviewed by psychiatry he says” “I did not shoot myself. Sure, I had the gun pointed at myself but it just went off.  I am not suicidal and I want to leave.” He gives the additional explanation that he was using large quantities of alcohol even though he has been hospitalized for alcohol poisoning in the past. When the psychiatrist points out the dangers of alcohol poisoning including death he says “Look I already said I was not suicidal.  I was just trying to get high.  I get to the point where I don’t care if I live or die but I am not trying to kill myself.”  He has had multiple admissions for depression and suicide attempts in the past.  He is currently on a 72-hour hold pending a court hearing at that time. The psychiatrist requests a review from the Ethics Committee composed of a number of local philosophy professors. They decide that the patient should be released despite the recommendation to the court for extended treatment of the substance use disorder and depression.  During the hearing the psychiatrist testifies that he has seen this type of treatment work and that he considers the patient to be at very high risk.  The court releases the patient. A week later he is found dead from acute alcohol poisoning.

Again, there are no major cultural differences in this case but clear subcultural differences based on the patient’s family and social history.  The psychiatric diagnoses are clear and indisputable.  The clinical judgment of the psychiatrist based on risk factors was also clear. The value judgments introduced here are the probate court and Ethics Committee as a proxies for society’s charge to balance a persons need for autonomy against their need for protection.  Those decisions were spread over multiple people and agencies outside of the field of psychiatry.  

These basic case examples (I say basic because they are encountered in acute care psychiatry every day and multiple times a day) illustrate a few facets of social objectivity.  First, it is poorly defined.  Second, it is impossible to achieve primarily because is consists of an infinite number of subsets that cannot be averaged if the expected result is to achieve active input into the field of psychiatry. Third, for social objectivity to be useful it needs to be recorded as unique for every person that comes into treatment and handled as it was in the above vignettes.  That way the relevant considerations of every unique history and constellation of signs and symptoms can be evaluated in the proper context. It turns out that technique has been around in clinical psychiatry for as long as I have been a psychiatrist and it is called cross cultural psychiatry.

For 22 years, I practiced on an acute care unit where we had access to professional interpreters who were fluent in both the language and cultures of several countries as well as the hearing-impaired population who used American Sign Language to communicate.  There were 15 language interpreters who spoke a number of African and Asian languages in addition to Spanish. Professional interpreters do a lot more than translate languages - they also interpret cultural and subcultural variations as well as normative behaviors. We had access to telephone interpreters in any language if we encountered a patient outside of the hospital staff expertise. The interviews were lengthy and often incorporated family members, community members, and in some cases local shaman. Without this intensive intervention attempting to assess and treat these problems would be a set up for the epistemic and hermeneutical injustices the author refers to. In fact, treatment would have been impossible. In completing these assessments there was not only an elaboration of the stated problem, how the relevant community conceptualized that problem, a discussion of how it may be treated psychiatrically and the rationale for that treatment, as well as whether the family wanted the patient treated in general or more specifically in the hospital and whether their shaman or medicine man would be involved.

These are just a few examples of how social objectivity is approached in clinical psychiatry.  The result is that values are incorporated that are important to the patient and their family even if they affect diagnostic thresholds and treatment planning.  That is also clearly stated in the DSM.  It is a much more practical and personalized approach than trying to incorporate all of those opinions into the DSM diagnosis and it gives a voice to many more people than would be involved in that process. It also considers a multitude of local factors (budgets and attitudes of social service agencies, budgets and attitudes of local courts, community resources, etc.) that all factor prominently in values-based decision making.

The other important aspect of an all-inclusive process for social objectivity is that the normative thinking of some - may result in exclusion rather than inclusion. Normative thinking based on beliefs can be political thinking and in the past two years we have seen that lead to fewer rights for women, the banning of books, a widening scope of gun permissiveness in a society rocked by gun violence, gross misinformation about the pandemic, and an attempt to overthrow the elected government of the United States. These are all good examples of how including normative thinking outside the scope of medical practice could lead to disruption of the entire field. The author suggests that the opinions expressed do not need agreement - they only need to be aired. That strikes me as the basis for a very bad meeting. Unless there is basic agreement on the values and rationale for a diagnostic system – I think Spitzer has a point that opinions for the sake of stating an opinion is a futile exercise especially if it is not in basic agreement with medical and psychiatric values and ethics.

The author defines hermeneutical ignorance in psychiatry somewhat clearer. He suggests that marginalized groups (like the pathologized) develop their own conceptual resources that are not shared with other groups.  The example suggests that willful hermeneutical ignorance results when the marginalized group does not share the conceptual resources and the dominant group (inferring psychiatry) are unaware of the resources or dismiss them.  There are numerous examples of how this is not the case with psychiatrists.  Obvious examples include Alcoholics Anonymous and other 12 step groups as well as community psychiatry programs that actively use advocates and develop resources with the active input from people with severe mental illness who are affiliated with specific programs. Psychiatrists see a general knowledge about non-psychiatric resources as necessary to provide people with additional assistance.  In many cases that can include discussions of how to better utilize the resource and what to expect.  

There are several additional points of disagreement with the author on many points where he seems unaware of how psychiatrists actually practice or he is unwilling to give credit where credit is due. The best example is his description of Spitzer’s brief commentary (2) on a paper written in Psychiatric Services. He was responding to a lead paper (3) on including patients and their families in the DSM process. The author characterizes Spitzer’s general attitude toward the idea as hostile and characteristic of injustices that he writes about but important context is not given.  Spitzer was the major architect of DSM criteria and studied the process for decades. He wrote a comprehensive defense of psychiatric diagnosis in response the Rosenhan study that has been discredited. He was also responsible for removing homosexuality from the DSM and he did that by directly engaging with activists who presented him with clear information about why it was not a diagnosis. Critics like to use the homosexuality issue as a defect with psychiatry while never pointing out it was self-corrected and that correction happened decades before progress was made at societal levels.  Even now there is a question about whether societal progress is threatened by the normative thinking and agenda of conservative groups. Spitzer was responding to the political aspects of the process with political rhetoric. 

The best argument against inclusion in the original paper was:  “The DSM process is already compromised by excessive politics.” by several groups who are not psychiatrists.  That argument has been expanded in the past 18 years to the point where it is a frequent criticism in the popular media. Even in the original paper the authors suggest that these political processes may have stifled innovation and scientific progress.

Psychiatry has not “escaped” from considering values – as noted in the above examples they are incorporated into clinic practice when the specific social and cultural aspects that apply to a certain patient are explored and considered.  Contrary to philosophical opinion – the pathologized are not a marginalized group to psychiatrists. It is who we are interested in seeing and treating.  Our interest in treatment goes beyond what is typically considered evidence-based medicine. We are interested in any modality that might be useful and that includes using resources developed or available to the people who need them. It is clear that the DSM has been overly politicized and it is routinely mischaracterized in the media. Adding  additional elements - some that have strictly political agendas that include the destruction of the field - adds nothing to improving that process. There are existing avenues for that input and they are readily available outside of the DSM process in day-to-day psychiatric practice.

 

George Dawson, MD, DFAPA

 

References:

 

1:  Knox B. Exclusion of the psychopathologized and hermeneutical ignorance threaten objectivity. Philosophy, Psychiatry, & Psychology. 2022;29(4):253-66.

2:  Spitzer RL. Good idea or politically correct nonsense? Psychiatr Serv. 2004 Feb;55(2):113. doi: 10.1176/appi.ps.55.2.113. PMID: 14762229.

3:  Sadler JZ, Fulford B. Should patients and their families contribute to the DSM-V process? Psychiatr Serv. 2004 Feb;55(2):133-8. doi: 10.1176/appi.ps.55.2.133. PMID: 14762236.

4:  Dawson G. More on epistemic injustice.   https://real-psychiatry.blogspot.com/2023/01/more-on-epistemic-injustice.html

5:  Dawson G.  Epistemic injustice is misapplies to psychiatry.   https://real-psychiatry.blogspot.com/2019/07/some-of-greatest-minds-in-psychiatry.html

A DSM for Psychiatrists?

 

 

No matter what version - the DSM is clearly a flash point for criticism by psychiatrists and non-psychiatrists alike. There are too many diagnoses.  People don’t like certain diagnoses or complain when some categories are eliminated. There are endless debates about diagnostic criteria, reliability, and validity. Categories are a wrong approach and we need dimensions. Philosophers have a field day imagining what the DSM is and making suggestions.  In an early post on this blog, I responded to the philosophical suggestion that the DSM was supposed to be a blueprint for living. Antipsychiatrists have no problem rejecting the entire volume of course because they are stuck in the 1970s with Szasz and maintain that there are no mental illnesses. The more flexible antipsychiatrists reframe this into everyday problems in living another decades old formulation that did not stand the test of time. Others suggest that the DSM exists to make diagnoses that lead to pharmaceutical treatment and make profits for drug companies.  The more legitimate criticism from psychiatrists is focused on the criteria and whether any diagnostic categories exist. Some of that criticism comes full circle back to why a classification system was needed in the first place. Clinical psychiatrists tend to use a fraction of the available diagnoses and in most practices can recall the diagnostic codes without looking them up. In fact, most psychiatrists use the DSM as a reference, pulling it off the shelf for rarely encountered diagnoses and then typically to look up a diagnostic code for coding and billing purposes. 

The title Diagnostic and Statistical Manual – is the first clue about the original intent of the manual and it antedates the psychiatric profession and the APA in the United States by several decades. The abbreviated history is available on the APA web site and several other Internet sites.  Initially it was to determine numbers of people by diagnosis both in the varied mental illness facilities across the country and later in military service. This function was described as administrative but there was also a consensus building aspect in the early 20^th century as diagnoses shifted from a unitary psychosis model to more nuanced.  The advent of the DSM-III was a turning point because it provided atheoretical definitions of disorders that were subsequently adopted by the ICD-9. Subsequent revisions in the DSM-IV and DSM 5 included revisions based on professionals and professional organizations, assigned work groups and their research, and eventually the general public. The original goal of classification and statistics has remained but it is used for various reasons by non-psychiatrists.

There are many examples of non-psychiatric use.  In the legal and political sphere, most states have rationed services for people with severe mental illnesses who are at high risk for hospitalization and other morbidities. Qualifying for those benefits depends on a  DSM diagnosis.  The same is true for state sponsored services for autism and developmental disabilities. In forensic settings experts are called upon to give diagnoses in an adversarial setting.  Disability, veteran’s benefits, and worker’s compensation are all linked to diagnoses.  All medical billing to insurance companies and government payers depend on DSM equivalent diagnostic codes in the ICD-11. Managed care companies ration care based on many of these codes by refusing to cover them. None of these functions were designed as an original intent for the diagnostic manual.

Heterogeneity – either explicit or implicit is another frequent criticism of the manual. Human biology and the biology of diseases and disorders teaches us that the etiopathogenesis of illnesses is diverse. There are many possible underlying biological and nonbiological causes.  Many genes and lesions can often lead to the same apparent presentation or phenotype.  That lead to the idea of intermediate phenotypes or endophenotypes to get a more consistent population to study but that has only been partially successful. The DSM was never designed to biologically classify mental illnesses, but DSM diagnoses are used for studies of biology and pharmacology. Other systems have been suggested for that purpose – most notably the RDoC system, but so far it has not exhibited any widespread success.  There is no reason to think that a verbally based system will accurately describe biologically based illness whether those descriptions are in the DSM or RDoC.

Apart from classification for statistical, administrative, and planning purposes what good is the DSM to psychiatrists? I recently saw it criticized for not including enough psychopathology. The criticism was bitter and partisan but apart from some very basic definitions the DSM is not a course in psychopathology.  All psychiatric residents need to be taught psychopathology to the point that they are experts in it. That will never happen from reading the DSM. It also doesn’t happen from reading a psychopathology text or taking a college course in psychopathology.  It happens from seminars, reading, and clinical experience – discussing psychopathology with colleagues, supervisors, and instructors.  It happens from learning in treatment relationships with people who have psychopathology not just a list or criteria but experiencing firsthand the interpersonal aspects. The DSM explicitly states that it is for use by trained professionals and that it can be used to facilitate communication between trained professionals.  

The DSM is clearly not a treatment manual of any kind. That is why I have always found the charge that it is a source of prescriptions for the pharmaceutical industry ludicrous.  There are roughly six times as many prescribers of psychiatric drugs as there are psychiatrists and the only medication in that category that is more likely to be prescribed by psychiatrists is lithium. It is easy to speculate that the prescribing patterns of that larger group are not contingent about what is in the DSM.

What about the diagnostic side and what psychiatrists need? Although there was some criticism that the neo-Krapelinians have had too much influence on the manual it is time to acknowledge that verbal descriptions have come to their logical limits. It is also time to acknowledge that psychiatrists need to know a lot more about medical diagnoses in general in order to function in a medical environment. If medical conditions are in the differential diagnosis – how many medical conditions do psychiatrists need to know about and diagnose?  Every psychiatrist I know has stories about medical conditions that were referred to them as a psychiatric disorder where they made the correct medical diagnosis. They are typically conditions from neurology, endocrinology, and infectious disease but also general medical conditions like diabetes mellitus, hypertension, and atrial fibrillation. Approaches I have seen in other specialties include lists of conditions that the trainee or practitioner needs to know about.  That is a useful approach but lists like that in a DSM are likely to raise objections about medicolegal risk and that a larger recipe book is being made for what it takes to be a psychiatrist. There are also many psychiatrists in settings where medical assessments are impossible, where they are referred out, or where the practitioner may feel inadequately trained. I see all of those reasons as being an opportunity to advance the quality of psychiatric treatment.   

A related issue is the diagnostic process in psychiatry as opposed to the rest of medicine.   Nassir Ghaemi, MD had a recent commentary about this on his blog suggesting that the DSM approach prioritizes comorbidities rather than differential diagnosis like the rest of medicine.  He describes the typical pattern matching that occurs early in the process and suggests that the differential diagnosis point, the DSM encourages listing all of the comorbidities rather than going through a differential diagnosis process.  In other words there is a lack of a hierarchical process. 

That has not been my experience. Granted – I may be a more medically oriented psychiatrist than most (but then again had 20 colleagues doing the same work) – but when I see a patient the universe of diagnoses are all possible both in and outside the DSM. The number one priority was making sure that a life threatening medical condition was not misdiagnosed as a psychiatric disorder.  Every physician can recall being taught about differential diagnosis and having to write an exhaustive list for the first few Internal Medicine inpatients. That process illustrated that a lot of the “rule outs” occurred as a mental exercise and really did not need to be written down. By the end of that rotation the differential diagnosis list collapse from the low double digits to the low single digits. There was also a triage element based on the more pressing problem or diagnosis.   A DSM for psychiatrists could make this process explicit, discuss the cognitive aspects of pattern matching and completion necessary for generating hypotheses in the differential diagnosis, the differences between differential diagnosis and comorbidity, and probabilistic considerations in selecting the preferred diagnosis. It would potentially have training implications because in order to optimize the pattern matching required - adequate training experiences need to be supplied to develop those skills. 

A DSM for psychiatrists needs to be much more information intensive in terms of research on validators, psychiatric genetics, multiomics, endophenotyping, drug mechanisms of action, and biological markers for each category.  A typical response to that suggestion is "Well there are no biological markers, labs tests, etc."  I don't find that to be a compelling argument when I think about what is currently being ignored.  We are on the cusp where more of that information is becoming relevant and we are past the point where much relevant information can just be dismissed. Any concern about cost of a more extensive manual can be dealt with by placing it online for subscribers. This may seem like a significant task given the accumulating information, but it is time the APA and research leaders in psychiatry to realize that the task has changed.  Psychiatrists are different from other physicians and other mental health professionals.  Psychiatrists need the technical information to provide quality care and compete against other systems that claim to know more about psychiatry and medicine than they do. Time to adjust to that reality and have the necessary internal debates first.

That concludes my suggestion for a DSM for psychiatrists, but I am open to more suggestions.  And for the record I am suggesting two different publications instead of a general manual full of qualifiers about expertise.  We need a manual for experts and another one like the current version - for everybody else.

 

George Dawson, MD, DFAPA

References:

1:  Horwitz, A.V. (2014). DSM - I and DSM - II . In The Encyclopedia of Clinical Psychology (eds R.L. Cautin and S.O. Lilienfeld). https://doi.org/10.1002/9781118625392.wbecp012

2:  Kim YK, Park SC. Classification of Psychiatric Disorders. Adv Exp Med Biol. 2019;1192:17-25. doi: 10.1007/978-981-32-9721-0_2. PMID: 31705488.

3:  Cooper R, Blashfield RK. Re-evaluating DSM-I. Psychol Med. 2016 Feb;46(3):449-56. doi: 10.1017/S0033291715002093. Epub 2015 Oct 16. PMID: 26470724.

4:  Shorter E. The history of nosology and the rise of the Diagnostic and Statistical Manual of Mental Disorders. Dialogues Clin Neurosci. 2015 Mar;17(1):59-67. doi: 10.31887/DCNS.2015.17.1/eshorter. PMID: 25987864; PMCID: PMC4421901.

5:  Blashfield RK, Keeley JW, Flanagan EH, Miles SR. The cycle of classification: DSM-I through DSM-5. Annu Rev Clin Psychol. 2014;10:25-51. doi: 10.1146/annurev-clinpsy-032813-153639. PMID: 24679178.

6:  Grob GN. Origins of DSM-I: a study in appearance and reality. Am J Psychiatry. 1991 Apr;148(4):421-31. doi: 10.1176/ajp.148.4.421. PMID: 2006685.

Supplementary:

It has been suggested that a hierarchical approach informs the usual differential diagnosis exercise but it may be the application of the parsimony principle. To me there is an open question about how well parsimony works for complex biological systems.

Photo Credit:  Eduardo Colon, MD