MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition.
As a child and adolescent psychiatrist my daily work involves diagnosing children and young people with various mental disorders. There are diagnostic manuals to guide me: the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the mental disorders section of the the International Classification of Diseases of the World Health Organisation, 10th Edition (ICD-10).
These manuals give algorithms and criteria by which diagnoses can be made. Since its third edition in 1980, the DSM has mostly followed the “medical model” of diagnosing by checking off lists of symptoms with little reference to past or present life stressors or the person’s coping or personality style. And ICD-10 followed the same post-DSM-III model.
Thus I dispense labels such as ADHD (attention-deficit hyperactivity disorder) for mainly boys with hyperactive or inattentive behaviour; if they’re particularly naughty they get the label ODD (oppositional defiant disorder) and if they’re being seriously nasty then CD (conduct disorder).
Nervous children may get a number of overlapping anxiety labels – OCD (obsessive compulsive disorder), panic disorder, GAD (generalised anxiety disorder), social phobia, separation anxiety disorder, or a number of other labels.
Some disorders such as anorexia nervosa or bipolar I disorder (once called manic-depressive psychosis) define more discrete and serious mental illness. But others such as bipolar II disorder (with milder manic symptoms), and all the NOS (not otherwise specified) disorders can blur with other labels.
Although schizophrenia is a very serious illness, transient psychotic symptoms are very common, even among the so-called normal young people who are under significant stress and of course under the influence of drugs.
Every few years an epidemic sweeps the nation’s schoolyards. In the mid-1990s it was ADHD; a few years ago an American epidemic of so-called PBD (pediatric bipolar disorder) touched a few here. Since then it seems a plague of Asperger’s disorder or ASD (autistic spectrum disorder) has struck many.
The DSM-5, due out next year, is likely to unleash a new epidemic – DMDD (disruptive mood dysregulation disorder), which has been strongly criticised by the former DSM-IV task force head Professor Allen Frances.
The question is what do the labels mean? They are rarely complete explanations in themselves; they label surface symptoms but not underlying causes.
Labels are useful in research where simplification is necessary. In clinical practice they sometimes are useful too, but almost as often they can distract or obscure the real issues rather than point to the right treatment options.
In psychiatric training, we learn that what really counts is a biopsychosocial (biological, psychological and social) formulation. This is a few paragraphs which accompanies the diagnosis, summarising the main relationships, genetic inheritance, stressful events, temperament and psychological coping style of the person. The biopsychosocial formulation seeks to uncover and put in perspective all the causes of their symptoms and point to what help is needed, even if not readily available.
Child psychiatry is not a cookbook discipline of simplistic labels with drugs ready for each label on some shelf. At worst, DSM labels totally obscure the real underlying causes by making everyone think they have an answer. University of Adelaide psychiatry professor Jon Jureidini has referred to such use of diagnostic labels to explain people’s predicaments as “unexplanations”.
This sentiment has been echoed elsewhere in the profession. In an address to the Royal Australian and New Zealand College of Psychiatrists, University of Sydney Professor of Psychiatry Philip Boyce commented:
“The current paradigm seems to be that if a patient suffers from a specific DSM disorder, then there is a specific medication for this. If that medication does not work, try some other medication… a number of trends have contributed to this: increased service demand, the deification of DSM, the influence of the pharmaceutical industry, a misunderstanding of evidence-based medicine (EBM), managerialism and the influence of consumerism. … The (simplistic) DSM approach is exemplified by …treating DSM disorders rather than individuals.”
Oxford Professor Andrew Scull summed the issue up in a Lancet article where he described the DSM-III as “an anti-intellectual system published in book form: a check-list approach to psychiatric diagnosis and treatment” by which “Patients and their families learned to attribute mental illness to faulty brain biochemistry”.
To be fair, three DSM diagnoses do relate to stress and trauma:
- RAD (reactive attachment disorder) in young children due to highly disturbed relationships with their primary caregivers;
- PTSD (post-traumatic stress disorder) but criteria are restricted to mainly life threatening events; and
- Adjustment disorder, where someone has more trouble than usual coping with a serious stress.
But stress weaves in through everyone’s life. In particular, complex childhood trauma and long-term outcomes of attachment problems are under-represented in the DSM.
One remedy would be the inclusion of DTD (developmental trauma disorder) into the DSM-5. But DTD seems to have lacked sufficient support in the APA’s DSM-5 committee. Most child psychiatrists find this a grave pity as DTD would add increased focus on the ongoing need for good child protection services.
In the end I’m glad my daily work involves broader, deeper and more commonsense thinking than simply dispensing diagnostic labels.
Taking the time to engage with young people, their families, and sometimes school counsellors and others, to explore and understand all the interacting causes and meanings of the troubling symptoms is rewarding. And it’s often successful, as natural healing mechanisms are unleashed when real causes are addressed.
This is the sixth part of our series Matters of the Mind. To read the other instalments, follow the links below:
Part seven: Redefining autism in the DSM-5