The arbitrary and often absurd rhetorical attacks on psychiatry

 

I drew the above graphic (click on it to enlarge) to highlight a few things about popular psychiatric criticism, but mainly that it is absurd.  I have commented on antipsychiatry rhetoric many times in the past and how it has a predictable pattern.  But this goes beyond antipsychiatry to include critics in the press, authors selling books (or being paid for lectures or appearances), and even critics in the field. I thought it might be useful to try to crowd as much of this rhetoric into one diagram as possible for easy reference.

Why is rhetoric so important?  Rhetoric is all about winning an argument.  The strategies are all well documented and you can read about them and the common fallacious arguments in any standard rhetoric or logic text.  My goal is not to teach rhetoric.  For the purpose of this post, I want the reader to understand that there is more rhetoric leveled at psychiatry than any other medical specialty. There is always a lot of speculation about why that might be – but nobody ever seems to come out and say the most obvious reasons – gaining political advantage or financial renumeration. There is also dead silence on the questions of facts and expertise - since practically all of the literature out there including much of the rhetoric advanced by psychiatrists is an overreach in terms of psychiatric knowledge and expertise.  When absurd rhetoric about psychiatry makes the New York Times or even prominent medical journals it is simply accepted as a fact. There is no marketplace of ideas approach or even a single alternating viewpoint. Some of the statements in the graphic are taken directly out of newspaper articles and they are absurd. 

I happen to believe that the best critiques of the field come from people who are experts and usually do not deteriorate into ad hominem attacks against the field or other experts in the field. I was trained by many of those experts who consistently demonstrated that a lot of thought and work goes into becoming a psychiatrist and practicing psychiatry. I have known that for 35 years and continue to impressed by psychiatrists from around the world who contact me every day.     

I sought feedback from psychiatrists through several venues about absurd psychiatric criticism, by showing them a partially completed table and asking for suggestions.  One suggestion was making a grid to evaluate plausible, implausible, and unproveable. I do not think that is the best way to analyze these remarks. There seems to be a lot of confusion about rhetoric versus philosophy and a tendency to engage in lengthy philosophical analysis and discourse. It turns out that a lot of what passes for philosophical critique of psychiatry is really rhetoric.  That rhetoric generally hinges on controlling the premise and arguing from there. For example – the statement that the DSM is a “blueprint for living” is taken directly out of a New York Times article where the author – a philosophy professor was critiquing the 2015 release of the DSM-5 on that basis. Never mind that no psychiatrist ever made that claim or even had that fantasy – there it was in the paper written like the truth. A reading of the first 25 pages of the manual would dispel that notion but it is clear nobody ever seems to do that. 

I seriously considered modifying the diagram based on a division proposed by Ron Pies, MD (1).  That would have involved dividing the area of the graph into a zone of “legitimate criticisms focused on problematic areas in psychiatry” versus “fallacious and baseless attacks ... aimed at delegitimizing and ultimately destroying psychiatry.”  As I attempted to draw that graph – I realized that I could not include any of the current statements in a legitimate criticism zone.  In order to do that I will need to find an equivalent amount of legitimate criticism and include it in a new graph.

This rhetoric has much in common with misinformation, except it has been around for decades. It is not an invention of the Internet or social media. An important aspect of rhetoric is that since it does not depend on facts it can be continuously repeated. That is the difference between the truth and facts versus rhetoric. The classic modern-day example is the Big Lie of the last Presidential campaign. Former President Trump stated innumerable times that the election was stolen by election fraud and at one point suggested that there was enough proof that it allowed the Constitution to be suspended. All that rhetoric despite no independent corroboration by any judiciary or election officials from his own party.  Major news services began reporting his claim as a lie.  Recent news reports revealed that the stars of the news outlet that Trump was most closely affiliated with - did not believe the election was stolen. Many of the statements leveled at psychiatry in the table are equivalent to the Big Lie.

Rhetoric typically dies very hard and that is why it is an integral part of political strategy. A current popular strategy is to use the term woke as a more pejorative description of politically correct. It creates an emotional response in people “You may be politically correct but I am not.”  The term is used frequently to describe many things including the teaching of Critical Race Theory (CRT) in public schools. Repetition alone has many Americans believe that CRT is being taught in public schools and that is something that they should actively resist. The fact is – CRT is not taught in public schools and yet the effect of the rhetoric has been enough to leave many people outraged and susceptible to political manipulation. The rhetoric itself is difficult to correct by a long explanation about CRT.  That approach will not win any arguments. The best approach is to characterize it for what it is at the outset – absurd rhetoric that is not reality based. But there is a good chance that will also not have much impact.

When I talk with psychiatrists about the problem of not responding to rhetoric – I typically encounter either blank stares, the rejoinder that “there might be a grain of truth there”, or  the suggestion that we should just ignore it and it will go away. Physicians in general seem to be clueless about the effect of politics and rhetoric on medicine and psychiatrists are no exception.  When you are trained in science and medicine, there seems to be an assumption that the scientific method and rational discourse will carry the day.  That may be why we were all shocked when the American people seemed to be responding in an ideological way to public health advice during the pandemic and they were so easily affected by misinformation. 

Rhetoric in science predates the pandemic by at least a century.  It has been suggested that Charles Darwin used natural selection as a metaphor for domestic animal breeding (1) in order to convince the predominately religious people and scientists of the day.  He had to argue the position that unpleasant natural states were intermediate steps leading to a more advanced organic state.  Without that convincing argument Darwin’s theory may not have received such widespread acceptance in the scientific community. It is useful to keep in mind that just presenting the facts is not necessarily enough to win an argument especially in the post truth environment that exists in the US today.

The “grain of truth” rhetoric is typically used to classify, generalize, and stereotype and may be more difficult to decipher than straightforward ad hominem attacks. A typical “grain of truth” argument in the graphic concerns pharmaceutical money being paid to psychiatrists and other physicians. Some psychiatrists are employed by pharmaceutical companies to conduct clinical trials and other business, some provide educational lectures, and more are passive recipients of free continuing medical education courses.  All of this activity is reported to a database where anyone can search how much reimbursement is occurring. From this activity it is typical to hear that psychiatrists are on the pay roll of, get kickbacks from, or are brainwashed by Big Pharma and KOLs (Key Opinion Leaders).  The reality is most psychiatrists have no financial conflict of interest and they are not free to prescribe new expensive medications because those prescriptions are controlled by for-profit PBMs (pharmacy benefit managers). Further – the entire issue was highlighted by a No Free Lunch movement that provided essentially rhetorical information about conflict of interest and how it affected prescription patterns.  Those arguments have a very weak empirical basis. 

What about just ignoring this rhetoric? Ignoring it has clearly not been a successful strategy.  Any quantitative look at antipsychiatry rhetoric and literature would clearly show that it has increased significantly over the past 20 years – to the point that papers written from this standpoint are now included in psychiatric journals and you can make money doing it.  Recent cultural phenomena including the Big Lie rhetoric of the last Presidential election, the partial recognition of climate change (despite firsthand experience with increasingly severe weather most do not believe it is due to human activity), and the multilayered problematic response to the coronavirus pandemic sends a clear signal that rhetoric must be responded to and not ignored. 

The American public has been fed a steady diet of absurd criticisms about psychiatry for decades. If you do not believe that – study the table and compare it to what you see in the papers and across the Internet.  And never take anything you read about psychiatry at face value.

 

George Dawson, MD, DFAPA

Supplementary 1:  As noted in the above post I am interested in graphing legitimate psychiatric criticism in the same format used in the above graphic. If you have critiques and references - feel free to post them here.  I have some favorites from Kendler, Ghaemi, and others. 

 

References:

1:  Pies R.  Four dogmas of antipsychiatry.  Psychiatric Times May 5, 2022:  https://www.psychiatrictimes.com/view/four-dogmas-of-antipsychiatry

2:  Herrick JA. The History and Theory of Rhetoric. 7^th ed. New York, NY: Taylor and Francis, 2021: 221-223.  – I highly recommend this book on the historical and current importance of rhetoric. A lot of what passes for philosophical criticism of psychiatry is really rhetoric.

Elimination of Homosexuality from the DSM - An Old But Important Story

I follow Michael Blumenfield's blog Psychiatry Talk and his most recent post reminds us that homosexuality was eliminated as a diagnostic category from the DSM 40 years ago.  Incredibly he interviewed the President of the American Psychiatric Association at the time of this decision and has these interviews posted on his blog.  Many years ago, I encountered a piece done on This American Life that documented another side to the process.  In that discussion Robert Spitzer one of the main architects of the DSM was directly influenced by his attendance at a parallel meeting of gay and lesbian psychiatrists - informally self titled the GAYPA.  He was apparently struck by the fact that homosexuality did not confer any disability in terms of psychiatric careers or social functioning and advocated for eliminating it from the DSM.

Dr. Freedman's interview (especially recording 2 and 3) starts to talk about the issues raised by the Committee for Concerned Psychiatry.(paragraph 4).  The major issues of the day were opposing the Vietnam War and homosexuality as a disease.  Dr. Freedman accepted their offer to be a petition candidate to oppose the "old boy's club" approach to APA presidency.  He describes the 1972 APA Annual Meeting in Dallas where a  gay APA member gave a talk wearing a disguise about how the DSM definition had harmed him.  He received a standing ovation.

Dr. Freedman refers to Spitzer as the Chair of a Task Force to look into homosexuality.  He prepared a document that supported dropping homosexuality as a diagnosis.  At the same time the APA Board and members were strongly in favor of it.  It was debated in committees on nomenclature, research and reference committees in a process similar to the recent DSM-5 process.  The evidence to maintain the homosexuality was found to be unscientific, based on highly selected samples and it was rejected.  The decision was front page news in both the New York Times and Washington Post.  On December 16, 1999 the Washington Post selected the APA decision as one of the "stories of the century."

There was not complete consensus and two psychoanalysts insisted on a referendum at the next election and their petition was defeated by a margin of 2:1.  Dr. Freedman provided this information because of criticism that the APA Board and not the membership favored the elimination of homosexuality.  He points out in retrospect that there were other issues that he was focused on at the time including the theft of psychoanalytic records during the Watergate scandal and the reaction to that incident.  He also raised the issue of psychiatric abuse in the Soviet Union and interview detainees who had been inappropriately placed in psychiatric hospitals.  The APA contingent refused to travel to the USSR unless they would have access to patients in psychiatric hospitals and could interview them.  The Soviets sandbagged the process by presenting cases of severe chronic mental illness and not allowing interviews.  

The 81 Words piece is given primarily by Alix Spiegel, the granddaughter of John Spiegel a past President of the APA.  At the time of this decision he was President Elect of the APA.  She waxes rhetorical at times about psychiatry but I won't dwell on those details.  They are minor in comparison with a well researched human interest story about the parallel stories that factored into this decision. She also discusses a parallel story within her family based on the occurrences at the time.

At the time that Dr. Spitzer decided to eliminate homosexuality as a diagnostic category he was probably early in his career in terms of designing diagnostic criteria and extending the DSM technology. He has described that process as basically reviewing literature, talking with experts and trying to type up a notecard with the criteria for that disorder. The MPR piece described his process with regard to the homosexuality question as more complex. He first met with a gay activist and wanted to understand that viewpoint. Several months later he arranged for three gay activists to present their case to the DSM nomenclature committee. A forum was organized at the 1973 APA Convention in Honolulu with an open debate between the analysts supporting homosexuality as a diagnosis, a faction of psychiatrists who did not, and Ronald Gold, the gay activist who befriended Spitzer. The event that led to the redraft that evening was Spitzer's attendance at the GAYPA party later that evening. After stating that he did not know any gay psychiatrists, he saw many notable psychiatrists at that meeting and went back to his hotel and redrafted the DSM criteria.

I have an interest in flagging these resources for future reference.  Listen to the This American Life piece and the interviews by Dr. Blumenfield.  This is a compelling story and clearly a decision that the APA and its membership got right.  A common criticism of psychiatry is that it is unscientific or pseudoscientific and yet one of the main points in this historic decision was the rejection of psychoanalytic research that was considered unscientific.  Dr. Freedman's commentary points out that the decision went through a process that seems to be very similar to the current DSM-5 process.  Contrary to the flurry of criticisms of the DSM-5 before the recent release, this decision was precedent setting.  It preceded most state laws regulating gay marriage by nearly 40 years.  It was hailed as recently as 1999 as being a story of the century.  And yet the press image of the DSM process suggested that the organization was socially inept and could not be trusted with similar decisions without close monitoring by non-medical organizations.

If anything this decision combined with precedent setting decisions on confidentiality, commenting on public figures, and banning psychiatry from participating in torture and capital punishment suggests that psychiatry should be one of the first professional organizations consulted.  Anyone reading this blog gets the message that the APA is far from perfect, but at times they get it very right.  This is a forty year decision that has stood the test of time and is also a good example of activism within the organization as a driving force.  Activism and political tension within the organization can be as important as the science behind the position.

George Dawson, MD, DFAPA

1.  This American Life.  81 Words.  January 18, 2002.  The NPR story of how the American Psychiatric Association decided that homosexuality was no longer a mental illness.

2.  Michael Blumenfield, MD. 40th Anniversary of "Homosexuality" Being Removed from DSM.

3.  DSM-II Change - The actual DSM-II change involved the category "Sexual Deviations".  The introductory paragraph was 81 words long and "302. Homosexuality" was removed from the list.  It begins with the sentences:

"This category is for individuals whose sexual interests are directed primarily toward objects other than people of the opposite sex, toward sexual acts not usually associated with coitus, or toward coitus performed under bizarre circumstances as in....."

UW Update - the Rest of the Story

I am back at my usual computer tonight and feeling much better after attending the UW Psychiatric Update. It was well attended and I estimate there were about 400 people there - mostly psychiatrists.  The conference brought in several people who were instrumental in the DSM-5 to talk about the thinking and research that went into it.  The resulting story is one that you will never hear in the press or other media.  The story is based on science as opposed to the irrational criticisms in the media and that science is written about and discussed by brilliant people.  I will try to post a few examples, and wish that it had been presented to the public.  The discussion produced for public consumption was not close to reality and it was a further example of how stigmatization of the profession prevents relevant information from reaching the public.  It seems that the most we can hope for is an actual expert being placed in a staged debate or responding to some off-the-wall criticism - hoping to interject a few valid points.  That is a recipe for selling the sensational and leaving out the scientific and rational.  Just how far off the media is on this story is a mark of how skewed that perspective is.

Let me start with the disclosures.  There were 14 presenters and 10 of them had no potential conflicts of interest to report.  That included one work group chair.  One of the presenters suggested that the political backlash against psychiatrists affiliated with the industry and the DSM limit on the amount of money that could be earned from the industry limited access to some experts and probably limits drug development.  His question to the audience was:  "What if it means that 10 years from, all we have to prescribe is generic paroxetine and generic citalopram?  What if we have no better drugs?"  It would be interesting to know who was specifically not able to participate in the process due to these restrictions.  There were primarily 2 presenters with extensive industry support primarily in their role as consultants to the industry.  One of them joked about his level of involvement: "Based on my disclosures you should probably not believe a thing that I say."  He went on to give an excellent presentation replete with references to peer reviewed research.



Before I go on to talk about specific speakers I want to address another frequent illusion about psychiatrists and that is that they are primarily medication focused and have minimal interest in other treatments.  That is convenient rhetoric if you are trying to build a case that psychiatrists are all dupes for the pharmaceutical industry and that drives most of their waking decisions.  During the presentation of the pharmacological treatment of obsessive compulsive disorder, the presenter clearly stated: "It could probably be said that we are still waiting for an effective medication for obsessive compulsive disorder."  Certainly, the section on autism spectrum disorder presented the current AACAP practice parameters and the fact that there is no medication that treats the core features but some that that have a "mild to modest" effect on some features or comorbidities.   Three of the four breakout sessions in the early afternoon of day 1 were psychotherapy focused.  I attended Mindfulness Based Cognitive Therapy and Recurrent Major Depression with about 200 other participants.  We were guided through two interventions that could be used in follow up individual sessions as well as groups.  The efficacy of preventing recurrent major depression with this modality alone was discussed.  The Psychotherapeutic Treatment of Insomnia and Pediatric Post Traumatic Stress Disorder were discussed in parallel sessions.  In the PTSD lecture, it was pointed out that there is no FDA approved medication for the treatment of this disorder and that the gold standard of treatment is Trauma Focused Cognitive Behavior Therapy (CBT).  That's right a psychiatric conference where the treatment of choice is psychotherapy and not medications.

What about he individual presentations on the thinking behind the DSM?  I was thoroughly impressed by Katharine A. Phillips, MD Chair of the DSM-5 Anxiety, Obsessive-Compulsive Spectrum, Post Traumatic Stress Disorder Work Group.  Reviewing the structure of the DSM-5 as opposed to the DSM-IV shows that all of these disorder previously considered anxiety disorders are now all broken out into their own categories.  She discussed the rationale for that change as well as the parameters that were considered in grouping disorders in chapters - clearly an advance over DSM-IV.  She talked about the two new disorders Hoarding and Excoriation (Skin Picking) Disorder and why they were OCD spectrum disorders.  She talked  about insight and how it varies in both OCD and Body Dysmorphic Disorder (BDD).   She discussed the new OCD Tic-Related Specifier and its importance.  Most importantly she discussed how the decisions of the Workgroup will improve patient care.  The most obvious example, is the case of BDD where both the delusional and non-delusional types respond to SSRIs and those are the drugs of choice and not antipsychotics.  By grouping BDD in with Obsessive Compulsive Disorder and Related Disorders recognition and appropriate treatment will probably be enhanced.  Dr. Phillips is the researcher who initially discovered the treatment response of BDD to SSRIs.  She is also a rare lecturer who does not pay much attention to the PowerPoint slides but speaks extemporaneously and authoritatively on the subject in a parallel manner.

Susan E. Swedo, MD was the Chair DSM-5 Neurodevelopmental Disorder Work Group.  She talked in detail about the elimination of the Pervasive Developmental Disorders diagnosis  and how the Autism Spectrum Disorder diagnosis reflected current terminology in the field over the past ten years and how it basically eliminated 5 DSM-IV diagnoses (Autistic Disorder, Asperger Disorder, Pervasive Developmental Disorder, Childhood Disintegrative Disorder, and Rett Disorder).  She pointed out that the Workgroup could only locate 24 cases of anyone who had ever been diagnosed with Childhood Disintegrative Disorder and that the CDC's epidemic of Autism was probably related to diagnostic confusion and overlap between PDD-NOS and Attention Deficit Hyperactivity Disorder. She gave a detailed response to the "publicized concerns about DSM-5" including decreased sensitivity to improve specificity, the loss of the uniqueness of the Asperger Diagnosis, and the fact that pre/post research in this area won't be comparable.  She showed a detailed graphic and comparison of DSM-IV and DSM-5 criteria to show why that is not accurate.

I came away from this conference refreshed and more confident than ever about the reason for writing this blog.  I had just seen some of the top scientists and minds in the field and why the DSM was really changed - not what you read in the New York Times.  If you are a psychiatrist - there were plenty of reasons for a DSM-5 and if you read this far, it is only the tip of the iceberg.

George Dawson, MD, DFAPA

DSM 5 Total Diagnoses Revealed

As any reader of this blog can recall one of my foci is to expose the anti DSM 5 rhetoric for what is was.  One the the main points by DSM detractors was diagnostic proliferation or more total diagnoses.  This implies more diagnoses, more prescriptions, and more money for psychiatrists and pharmaceutical companies.  Another spin was that it was the intent of organized psychiatry to "pathologize" the population.  I put up a table on this issue in a previous post and at that time did not have the final number of diagnoses.  As of today I have the final number and it is 157.  According to the presenter that means that a total of 15 diagnoses were eliminated from DSM-IV to DSM 5.  The total diagnoses in DSM 5 did not increase as the detractors predicted - they decreased by 15.

I was at a conference today put on by the University of Wisconsin Department of Psychiatry entitled Annual Update and Advances In Psychiatry.  The Introduction by Art Walaszek, MD acknowledged that this was the first in a series that replaces a long tradition of courses run by John H. Greist, MD and James W. Jefferson, MD: "Jeff Jefferson and John Greist ran this conference for 31 years."  That is an amazing track record and record of achievement and a contribution to psychiatry in the Midwest.  I don't know of many psychiatrists who were not aware of this conference with the alliterative titles like:  "Quaffing Quanta of Quality from Quick Witted Quinessentialists" or the Door County Course they regularly taught.  They have been a model of scholarship and professionalism and continue to be.

The first speaker today was Alan Schatzberg, MD.  He posted the information about the total diagnostic categories in DSM 5 an other important changes and how they occurred.  Per my previous post about the DSM 5 lectures by Jon Grant, MD the DSM 5 effort was outlined in addition to some critical information on how stigma affects psychiatric diagnosis.  For example, when the DSM 5 work group wanted to add mild neurocognitive disorder a well known historian of psychiatry came out and said it would add countless people who had normal memory impairment associated with aging.  When neurologists added mild cognitive disorder to their diagnostic nomenclature (an equivalent diagnosis) no such claims were made about neurologists.  In terms of the effort, Dr. Schatzberg pointed out that there were 13 conferences from 2003-2008 that produced 10 monographs and over 200 journal articles.

Dr. Schatzberg and his colleagues presented a ton of information today on what really happened with DSM 5 development.  I will try to summarize and post additional comments when I can post from a more user friendly computer.  I wanted to keep the post more on the scientific and debunk another common refrain from the naysayers before the DSM 5 was printed.  That involved the so called "bereavement exclusion" that basically says that a person cannot be diagnosed with major depression if they are seen during an episode of grief.  One question that was never brought up in the popular press "Where did this convention came into the diagnostic criteria in the first place?"  I quoted a text from about the same time (see third from last paragraph) that makes this convention seem even more arbitrary.  It turns out the original bereavement exclusion began in DSM-III not from any research basis but from convention that was subjectively determined by the authors of DSM-III.  Contrast that with the research done by Zisook,  et al. You would think that some of the self proclaimed level headed skeptics out there would have referred to this critical paper on the issue rather than speculative attacks on the field.  Incorporating these scientific findings was one of the reasons that the DSM was updated.

Stay tuned for more of the hard data and insider info on DSM 5.

George Dawson, MD, DFAPA

1: Zisook S, Corruble E, Duan N, Iglewicz A, Karam EG, Lanouette N, Lebowitz B, Pies R, Reynolds C, Seay K, Katherine Shear M, Simon N, Young IT. The bereavement exclusion and DSM-5. Depress Anxiety. 2012 May;29(5):425-43. doi: 10.1002/da.21927. Epub 2012 Apr 11. Review. Erratum in: Depress Anxiety. 2012 Jul;29(7):665. PubMed PMID: 22495967.

Supplementary 1:  The DSM-5 Guidebook by Donald W. Black, MD and Jon E. Grant, MD came out in March 2014.  Table 1.  (p.  xxiii) lists the total diagnoses is DSM-5 as 157 excluding "other specified and unspecified disorders". 

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