I remember feeling rather smug as a brand new child psychiatry fellow in 1987 when DSM-IIIR was released because I knew that this Chinese menu approach to diagnosis could not possibly do justice to the nuanced complexity of any individual patient. And of course I was correct – except in my smug attitude.
As fate would have it, three years later I found myself in a research fellowship at Columbia University that involved, among other things, participating in field trials for defining symptoms sets for DSM-IV childhood disorder criteria – the first such comprehensive epidemiological effort in the United States, ever. In fact I was selected as one of a few “gold standard” clinicians against which computerized symptom algorithms were being assessed. So ironically the “menus” I had deigned to use, were now being referenced to my own best judgment. As you can imagine, it became harder to trivialize the process!
Guess what? There wasn’t a single pharmaceutical industry dollar involved in this childhood symptom study and the desire to “get it right” was fueled in significant measure for almost everyone I met by a genuine awareness and concern for the suffering of children whose needs were going unaddressed, in part because of the policy ignorance that resulted from their conditions being ill-defined.
It’s easy to take pot shots at the DSM’s focus on observable and generalized attributes when what makes us most human is unique and unreproducible. There has also been a recent media flap over whether DSM is neuroscience-based enough. I suppose by 2050 it will indeed look quite biologically naive. But this is 2013 and we need to do the best we can with what we have at our disposal.
And this is the point. We can use DSM-5 in the service of helping people, without for a moment reducing people to its categories. By the way, it won’t be clinically or humanly correct to reduce people to the neuroscientifically fancier categories of 2050’s DSM-7 either.
For more information on the American Psychiatric Association’s recently published DSM-5 see Dr. Joel Oberstar’s presentation handouts.