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Psychiatrists: DSM-5 fails to account for disorder origin

The new edition of the Diagnostic and Statistical Manual of Mental Disorders — set to be published next year — will not address the root causes of psychiatric disorders, according to two Johns Hopkins University psychiatrists who recently published an essay in The New England Journal of Medicine.

According to Paul R. McHugh, MD, and Phillip R. Slavney, MD, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), may provide new diagnostic categories, update criteria and emphasize degrees of severity, but the book will not separate psychiatric disorders into causally intelligible groups.

“Disregard for this issue — after 30 years’ experience with an appearance-driven policy — makes these proposed changes for the DSM-5 seem small,” they wrote. “The big question — ‘What are these disorders?’ — will remain unaddressed.”

Before the DSM III was published, psychiatrists used a “bottom-up” method of diagnosis, which required examinations of mental status, detailed life history and corroboration from third-party informants, according to McHugh and Slavney. However, that “painstaking” methodology was replaced by a superficial “top-down” approach that relied on symptom checklists.

The checklist diagnoses prevent psychiatrists from knowing their patients thoroughly, they added. Furthermore, pharmaceutical companies can profit from a diagnostic category that is based on checklists by promoting its recognition.

“Together these problems expose a critical issue of design in the DSM,” the psychiatrists wrote. “By forgoing thought about causation in identifying psychiatric disorders, the manual promotes a rote-driven, essentially rule-of-thumb approach to the diagnosis and treatment of patients — and there is no obvious way of escaping the practice.”

McHugh and Slavney said the criterion-driven diagnoses in the DSM cannot be abandoned because clinicians have grown accustomed to them and investigators cannot give up the usefulness of inclusionary and exclusionary diagnostic criteria. However, they proposed a solution to what they refer to as the “naturalist’s field guide” approach in the DSM. Mental disorders, they wrote, stem from four interconnected but separable categories — diseases, personality dimensions, behaviors and encounters — and DSM entities could be rearranged based on those four causalities.

“Grouping disorders by putative causation would promote fruitful thought and, consequently, progress,” they wrote. “Clinicians who were aware of the causal proposals and their several practical, heuristic implications would be encouraged to proceed more analytically in their assessments, treatments and investigations of patients, while still using the DSM diagnoses for their records.”

Disclosure: the researchers report no relevant financial disclosures.