Chapter 4 of PBM, “Probing the Boss Text: The DSM—What? Whither? How? Which?” is devoted to discrediting the DSM, in terms of the process used to create it, allusions to scientific foundations that are sketchy at best, various political and financial conflicts of interests attached to its creators, and more questioning about the “validity” of mental illness as a whole.
As I have discussed previously, I agree there are serious flaws in the DSM along the lines which BB suggests, leaving the question of how exactly “mental illness” is carved up into these individual disorders somewhat sketchy.
The Argument
Starting with the section “Activating the Text,” BB then proceeds to make the case that diagnosis is the primary, if not sole, driver of all that follows in the psychiatric system. You see a psychiatrist, you get a diagnosis, you are necessarily treated, which is done solely on the basis of that diagnosis, etc.
If the initial diagnosis (from the flawed DSM) is meaningless, the argument would go, all that follows is flawed.
Again, sounds logical enough. Let’s probe deeper.
The Necessity of Diagnosis
To quote from PBM:
While hypothetically, the practitioner separates those allegedly with “mental disorders” from those without, in point of fact, that is neither what happens nor what the system mandates. The practitioner rather is tasked with the job of assigning a diagnosis… A veritable diagnostic imperative is at work… The question then is not whether or not someone seeing a psychiatrist or psychologist will be assigned a “disorder.” The question is which disorder.
It’s true in one sense that if you see a psychiatrist, there will be a diagnosis assigned. For doctors to get paid by insurance companies (e.g. HMO’s etc. in the USA, provincial government health insurance plans in Canada) they need to provide along with your personal identifying information a “procedure code” (i.e. what they did for you) and a diagnosis code. This is incidentally true for all types of doctors, and all types of illnesses. It’s not restricted to mental disorders or psychiatrists.
Is the sole goal of an interview to arrive at diagnosis? Again, quoting from PBM:
[Tools like the Structured Clinical Interview for DSM perform] the all-important function of helping practitioners fill the empty shell of one the criteria sets with details of the patient’s life. The purpose of clinical interview per se is to arrive at the diagnosis… While the patient telling his story may be under the impression that a normal or quasi-normal conversation is going on, essentially behind his back a complex text-act sequence is under way.
While a diagnosis will indeed be found in every psychiatric assessment/consultation report, these multi-page reports also include far more information than what is strictly required to arrive at a diagnosis. More on this shortly.
Symptom Threshold
So far we’ve agreed with BB that a diagnosis will exist, even for pro forma reasons, e.g. billing.
But BB would like to distract us from the fact that diagnostic criteria require a certain threshold to be met, essentially that the behaviour/problem/stressor has to be clinically significant. The DSM makes some attempt at codifying this, and the five years of psychiatry training every psychiatrist receives provides further positive and negative examples of meeting criteria. There are grey areas and some amount of subjectivity to be certain, but overall there is general agreement about what it means to meet each criteria.
But an important criterion for being diagnosed with any mental illness is the following:
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Again, clinically significant is not as flimsy as BB would have the reader believe. Moreover, if you ask most people seeking help for mental health problems if their symptoms are getting in the way of different aspects of their life, they would be able to provide an answer.
So yes, your doctor may bill your insurance saying you have a catch-all diagnosis like “Mood Disorder Not Otherwise Specified,” but that is far different from saying you have an actual mental health diagnosis that is significantly impairing your life.
The Treatment Imperative
Which in turn brings us to the next point. The argument in PBM implies that you receive a diagnosis, and on the sole basis of that diagnosis necessarily receive treatment. This is patently false.
While a diagnosis might suggest what treatment options might be appropriate for people with that disorder who are seeking treatment, it does not determine if and how you are treated. This is determined by your individual symptoms and their severity, and in almost all cases, your own choices.
If I sprain my ankle, would I automatically get it treated? For a mild sprain that isn’t affecting me much, it’s very unlikely, and I doubt I’d even go to a doctor. For something a bit more severe, I might see the doctor, who might well tell me to just give it a rest, i.e. not treat. Or they might propose some noninvasive treatment such as a support or brace of various sorts, or something more invasive like surgery. Am I compelled to agree? No.
In all these cases, both my doctor and I would be weighing the costs and benefits of the treatment against the costs and benefits of leaving it untreated. Severity of the illness is a definite factor in this process, not just the actual diagnosis. Mental illness is no different.
For a reinforcement of this discussion, I’d refer you to an excellent blog post by Natasha Tracy entitled Mental Illness is Only a Problem When Mental Illness is a Problem.
More Arbitrariness
Some other smaller arguments are made to discredit the construction of diagnoses in the DSM.
I’d mentioned previously the “Not Otherwise Specified” notion, which PBM ridicules:
[NOS]… undermines the very concept of “criteria.” By these maneuvers, note, something qualifies as a disorder either if it meets or fails to meet stated criteria.
As noted previously, one “use” for such diagnoses is purely for billing purposes, where the physician doesn’t think the patient actually has a mental illness. Someone will see a physician because they are concerned about their mood. After hearing their story, the physician will conclude that what they are experiencing is a normal emotion, part of normal human experience, and that they don’t have an illness. This happens quite often, despite BB’s claims to the contrary.
Alternatively, while the arbitrariness of the criteria (and for example, needing five of seven symptoms to meet criteria) is criticized, “Not Otherwise Specified” is also used to specify an illness that may not fit into one of the standard boxes, yet is still severe enough that it is causing “clinically significant distress or impairment” to the patient. In other words, patients won’t need to be left to suffer with severe illness just because the categorization doesn’t quite fit.
Another criticism of the DSM is that mental illnesses are classified in such a way that:
… it is possible for two people who have no symptoms in common to receive the diagnosis of [a specific mental illness]
Again, we’d find that many “medical” illnesses exhibit similar patterns (Crohn’s disease, which can present in a multitude of different ways in different people, springs to mind).
Reconceptualizing the DSM
With the above in mind, let us reconsider the role of the DSM in actual practice.
Does it create illnesses ex nihilo (Latin for “out of nothing”; doesn’t fancy terminology give me credibility and make my argument stronger?) which are then necessarily applied to all patients, who then automatically proceed forward to treatment based on their diagnosis alone? Plainly, the answer is no.
The illness already exists in the patient, as a set of symptoms, severities, and impacts on their life. What the DSM does is take that illness and attempts to classify it. This is for several reasons. First are for mundane, administrative purposes such as billing.
Second, this serves (imperfectly) as a means to suggest treatments. As noted in an earlier section, it is for this purpose that the DSM is most-often abused by those with vested interests in applying particular treatments to as large a range of patients as possible.
Finally, as all classification tools provide, it serves as a way to decompose a larger problem (“mental illness”) into something more manageable so as to more easily conceptualize, understand and problem solve. This property also allows it to more effectively serve as a communications tool between different practitioners, a shorthand or placeholder (but not a replacement) for describing a whole range of symptoms, behaviours and effects.
Oddly, BB’s rigorous institutional ethnography did not reveal to us this common and important use of the DSM in actual practice.
From this new vantage point, the multiple iterations, changing perspectives, and differing conceptualizations of illnesses between versions can be seen not in terms of a changing understanding of some underlying physical process, but as (ideally) improvements in their effectiveness for allowing clinicians to conceptualize and communicate about mental illness.
Mental illness exists. It’s not the (at times arbitrary, or politically influenced) divisions in the DSM that make it exist.
