There’s a great (and long) article in the January 2011 Wired magazine profiling Allen Frances, lead editor of the DSM-IV and an outspoken critic of the process by which the American Psychiatric Association (APA) is developing the next version, the DSM-5. It’s worth a read and can be found here, as it provides a revealing look at a process that, according to the author (somewhat melodramatically, I might add) could make or break modern psychiatry.
I have many feelings about what’s written in the article, but one passage in particular caught my attention. The author, Gary Greenberg, writes that he asked a psychiatrist (in fact, a “former president of the APA”) how he uses the DSM in his daily work.
“Did it change the way you treated her?” I asked, noting that he’d worked with her for quite a while without naming what she had.
“So what would you say was the value of the diagnosis?”
“I got paid.”
I include this excerpt because the “hook” here—and the part that will most likely attract the most fervent anti-psychiatry folk—is the line about “getting paid.” But this entirely misses the point.
See, the DSM-5 is easy to criticize because it seems like a catalogue of invented “syndromes”, from which any psychiatrist can pick out a few symptoms (some of which, I would venture to say, both you and I are experiencing right now), name a diagnosis, and prescribe a medication—and get paid by the insurance company because he believes he is confidently treating a “disease.” But the truth of the matter, if you talk to any thoughtful psychiatrist, is that, more often than not, the book gets in the way.
In the example above, the doctor had seen his patient for several sessions but hadn’t yet come up with a firm diagnosis. He settled upon OCD because he was required to write a diagnosis on some form or another. Yes, ultimately to get paid, but I think we’d all agree that professionals deserve to be reimbursed for their time. (And if he’s actually listening to his patient instead of comparing her symptoms to a list in a book, his patient would probably agree as well.)
Did this woman have OCD? Judging by his hesitancy, it’s arguable that perhaps she didn’t have all of the symptoms of OCD. But she was probably suffering nonetheless, and such presentations are typical of most psychiatric patients. Nobody fits the DSM mold, we all have quirks and characteristics that present a very complicated picture. I would argue that this psychiatrist was probably doing well by not rushing to a diagnosis, but instead getting to learn about this woman and develop a treatment plan that was most appropriate for her.
The article’s author writes that if the DSM-5 is a “disaster,” as some observers predict it will be, the APA will “lose its franchise on our psychic suffering, the naming rights to our pain.” Quite frankly, this could turn out to be the best possible outcome for patients. If we as a profession ditch the DSM, and stop looking at patients through the lens of ill-defined lists of symptoms, but instead see them as actual individuals, we can better alleviate their suffering. Yes, a new system will need to be devised to ensure that we can prescribe the interventions that we believe are most appropriate (and yes, to get paid for them), but a patient-centered approach is preferable to a formula-based approach anytime.