The Art of Diagnosis

Friday, February 12, 2010


This week, the American Psychiatric Association released proposed changes to the Diagnostic and Statistical Manual of Mental Disorders, or DSM. In an update to a story that originally aired in December of last year, Brooke looks at this powerful book and the controversies surrounding the proposed revisions.

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Comments [10]

Margaret from Montana

I am a Licensed Clinical Social Worker in private practice, and use the DSM daily as the manual for coding diagnoses in order for persons to get mental health treatment.
Meghan M. makes a crucial point when she notes that the "main criteria missed in this piece is the key words - to a marked degree." Every diagnosis in the DSM specifies that the symptoms or behaviors relevant to diagnosis interfere significantly with the person's functioning, and in multiple settings (so, not just at home, but also in one's vocation, in the general community, within personal relationships, etc.)
Secondarily, while there are codes that denote life's challenges that may bring a person in for therapy (V61.20 - Parent-child relational problem; V61.1 Partner relational problem; or Sexual abuse of Adult [rape] --
coded as 995.81 if the clinical focus is on the victim, V61.1 if it is on the offender) insurance companies will not reimburse for these codes. If a person wants/needs therapy, but wants/needs insurance to cover it, then the clinician must use a diagnostic code. This, I believe, is one of the failures of our health care system -- instead of preventing further debilitation (medical or mental) by paying for preventive or early intervention care, the pay system requires debilitation.

Feb. 21 2010 10:23 PM
Chris Gray from New Haven, CT

I don't know Mr. Skarin. As a kid who grew up in a home where I only remember baseball in black and white (after the Dodgers left Brooklyn, the game was never even mentioned again), I would tend to diagnose liking baseball as a mental disorder. Then, again, I'm only a volunteer social worker.

Feb. 18 2010 03:25 PM
Lawrence Skarin from Rochester New York

The DSM ought to be renamed Manual for the Full Employment of Social Workers.

One of these days not liking baseball will be an indicator of a mental disorder.

Feb. 16 2010 12:40 PM
Tracy Carpenter from Greensboro, N.C.

As a psychiatric nurse with 30 years of experience, I am intimately familiar with both the value and the risks inherent to diagnosis with a mental illness or condition. One thing we should all remain aware of is the powerful influence of the insurance industry on use and abuse of diagnoses. Largely in the name of protecting their profit margins, these companies are responsible for limiting care, forcing diagnosis, or penalizing patients who need legitimate care. The vast majority of mental health practitioners in the field today are fighting for the health and well being of the clients, and the DSM is an extraordinarily well researched tool that has a valuable place in their arsenal. It behooves us all to seek the best and most well qualified practitioners for our needs, and to work to keep the insurance lobby out of our treatment rooms.

Feb. 14 2010 09:00 PM

Overall a very interesting and balanced story. However, I note that Psychiatry is hardly unique in its quest for more objective and comprehensive diagnostic tools, or in dealing with symptoms and physiological function that are also exhibited in people who are not ill. Michael First's comparison with treatment of somatic pain should have been followed up. Most areas of medicine deal with the question "is this abnormal [debilitating] enough to warrant treatment?" Medical conditions for which there are objective diagnostic tools are still minority, and for those, the physician must still consider other factors in deciding on treatment. What contributes more to the "exceptional" status of Psychiatry and Psychology in medicine is the public's and media's polarized view of mental illnesses. Why do we still have as the two most common reactions to a DSM diagnosis either skepticism or stigmatism? (For example, skeptics often claim that those with mental illnesses handicap themselves with their behavioral or lifestyle choices, but that argument is also valid of patients diagnosed with diabetes, asthma, heart disease and arthritis.) I agree with Brooke on the point that it not useful to ask "what is normal?". But if we could react with sympathy and pragmatism when someone struggles with a mental illness, just as we do when they have asthma, we'd make progress.

Feb. 14 2010 12:19 PM

Have you noticed that women tend to be hysterical from the point of view of psychiatrist? Pre-menstrual syndrome, dysmorphic disorder, malingering by proxy (manchausen by proxy) ? Were you old enough to remember "hysyterical paralysis" which is now called MS (multiple sclerosis)? folks, they used to hospitalize these mostly women in a psychiatry ward. These days, diseases like lyme disease, fibromyalgia and the so called "chronic fatigue syndrome" (such an insulting name for a very serious and debilitating disease) are for the most part marginalized diagnosis, where a big part of the patients are offered ant-depressants or psychotropic drugs, while the medical researchers haven't bothered researching these diseases properly, or governments haven't allocated appropriate amounts of money for research in order to find out the real causes. I want to caution decision makers that appointing psychiatrists at the head of CDC departments (like CFS) has succeeded to marginalize the disease even more, debilitating hundred of thousands of people for DECADES and denying research money since the outbreaks of epidemics in the early 1980's. Doesn't that sound a remake of "hysterical paralysis" ?

Please be very cautious in re-writing the DSM-5, for labelling people in a category is a ticket to disabling people's potential FOR LIFE.

Thank you for talking about this very important topic. The people, not just psychiatrists that have an agenda, have the right to have a voice.

Feb. 14 2010 12:04 AM
Tina Tidmore from Clay, Alabama

This concern has been an international issue in the chronic fatigue syndrome / myalgic encephalomyelitis debate. I am actually surprised that heated battle was not included in this report.

The question is whether the illness continues as a neurological or is changed to psychiatric / psychological. As politicians know, labeling is very powerful. Drug companies would love to have over 1 million in the US declared to have a "different kind of depression," as some doctors already believe.

Yet, published studies show the abnormalities in ME/CFS include neurological abnormalities, immune system abnormalities, latent virus reactivation, endocrine system abnormalities, metabolism abnormalities and more.

A multi-system disease is hard to pigeon hole. Just as humans be "liberal" on some issues while being "conservative" on others, can be mixed race instead of just "African American" or "white", humans can have complex illnesses that don't fit in human-created categories.

Feb. 13 2010 11:22 PM
Cathy W. from Long Island, New York

I found this very interesting and have put a link to this on Most of us ended up on psychiatric drugs -- most notably anti-depressants -- based on a single snapshot incident in our lives. In my own case I was dealing with family problems and had experienced one morning of feeling lightheaded and almost passing out. My GP instantly said that due to these problems I should be on Paxil -- and incidentally -- it would also help my PMS. Here is the upshot -- Paxil destroyed my life physically, financially and emotionally. I went through a long, painful withdrawal where I battled severe suicidal ideation for months and months, among many other issues.

Thank you for this program. I hope that more doctors will listen and become more responsible. My story is far from unusual.

Feb. 13 2010 03:25 PM
Meghan M. from Boston, Ma

I am currently finishing my advanced degree in education psychology. The main criteria missed in this piece is the key words - to a marked degree. A good clinican would take into consideration if these symptoms impact the client's life to a marked degree in the client's opinion.

Yes, diagnosis is an art and should be undertaken carefully. Hopefully these clinicians are making a diagnosis based on each individual client and not the treatments available.

Feb. 13 2010 01:56 PM
Jerry Moy from NY

Tremendously timely and appropriate.

Feb. 13 2010 08:21 AM

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