The American Psychiatric Association recently published a new version of the Diagnostic and Statistical Manual (DSM). The DSM-5 is what medical, mental health, and chemical dependency professionals use to diagnose developmental, mental health, substance abuse and dependence, learning, and personality “disorders.” Now in its 5th edition, the DSM was first published in 1952. At that time, the DSM was 129 pages containing 106 diagnoses.
Now, 61 years later, the DSM-5 consists of approximately 950 pages and roughly 375 diagnoses. The DSM-5, while researched far more than previous editions, is based on the medical model or the model of disease. Simply put, the medical model finds the causes of disease and illness and then prescribes a treatment to cure the disease or illness. This means a person has a pathology or pathogen that needs to be treated and cured.
The questions that eat at me during my day as a psychologist and at night as a person searching for answers are:
- Is it possible to accurately identify mental health “issues,” “illness,” or “disorders?” versus extreme ranges within the sphere of the human condition?
- Even if it is possible to identify these conditions, does it determine the course of “treatment” or “intervention?”
- If so, is there a “treatment” for every identified “condition?”
- Does it mean there is a treatment that works?
- Do you need a diagnosis to get help?
Over the years, many have been critical of this approach to mental “health” issues. Referring to mental “health” is actually a newer name as people have historically been thought to have mental “illness.” This makes more sense for people who are unfortunately compromised by severe conditions termed schizophrenia, bi-polar (manic-depressive), and severe depression and anxiety. But does this make sense for children, adolescents, and adults who are challenged with some other, and possibly less severe, aspect of their functioning and development? Do all human problems warrant a medical or mental health diagnosis? When did a weakness become a “disorder” that requires “intervention” and/or “treatment?”
To be fair, the DSM provided structure and guidelines for approaching the complicated business of determining who had a “problem” that required help. However, it seems things have gone too far. Critics of the DSM believe that this latest edition has taken the business of diagnosing to a new level, one where approximately 50% of the population can be diagnosed with something. Critics also believe that this pathology finding approach supports the continued trend of medication prescribing as the number one mode of treatment, and continued trend of increased health care costs and premiums with increased utilization of individuals who need a “diagnosis” to meet “medical necessity” to receive services. What does that mean? It means if you don’t have a diagnosis, you don’t get help. It means you have to have a problem (pathology) to get help (treatment and intervention).
Without going into detail about some of the changes in the newest edition of the DSM, some diagnostic categories have been added and some diagnosis “thresholds” have been lowered. This means that you need fewer symptoms to “meet diagnostic criteria.” Here are some examples of concerns with the new DSM-5:
- Temper tantrums will now be diagnosed as Disruptive Mood Dysregulation Disorder
- Normal forgetting will now be diagnosed as Minor Neurocognitive Disorder
- Gluttony will be diagnosed as Binge Eating Disorder
- Grief will be diagnosed as Major Depression
- First time substance users and college partiers will get a diagnosis of Substance Use Disorder
- Everyday Worry will be diagnosed as Generalized Anxiety Disorder
And what’s the number one treatment for all of these diagnoses? Medication. In my 20+ years of working with children, adolescent, adults, and families, I have found some simple and profound truths. First, if you talk to people about what is wrong with them and causally assign diagnostic labels to explain them, they feel badly about themselves and it plays into their low self-esteem, self-confidence, and self-worth. Next, if you help them to better understand their strengths and weaknesses, and help them to develop tools to cope with life, all of the aforementioned increases. Lastly, if you focus on their strengths, rather than their “deficits,” “disorders,” and “illness,” they become aware of neglected and unknown aspects of themselves that they can and do use to navigate life and meeting their goals.
Nothing in life that is worth anything is easy, simple, or clear. The issue of the new DSM and diagnosis is one of these. I am not saying that they both do not serve any purpose, but I am saying that they deserve very careful consideration and understanding when using either of them. I am far too aware of the need to play the game of diagnosis for insurance reimbursement and school accommodations. I am not suggesting making up diagnoses to get benefits for a client, but rather without a diagnosis, no doors – either financial, treatment, or accommodation – can open. You cannot get help if you have a significant deficit in understanding people’s facial expressions and emotions, but you can get help if you have Aspergers Disorder (now called Autistic Spectrum Disorder); you cannot get help if you have executive-functioning weaknesses and challenges, but you can get help if you have ADHD.
I ask that all mental health and medical providers, educators, administrators, adults, and parents think critically when making or accepting a diagnosis.
- What is the purpose of making or accepting a diagnosis?
- Does it fit my or my client’s experience?
- How will I explain the diagnosis to my client?
- What does this diagnosis mean to me (client)?
- Will this diagnosis help my client (help me) achieve my goals?
- Does the diagnosis explain a normal human emotion or condition?
- What are all the possible helpful interventions? Can medication wait?
- What is right with my client? What is right with me (client)?
Those of us in the field of mental health and medicine have a minimal obligation to do no harm. Further than that, we have an obligation to improve the life conditions of our clients. Our current mental health and insurance system makes this very hard, but nothing in life that is worth anything is easy.
Dan Peters, Ph.D., is co-founder of the Summit Center, which provides educational and psychological assessments, consultations, and treatment for children, their parents, and families. Summit Center works with all kids, including those who are highly gifted and those with learning disabilities.