Diagnosis in mental health is detailed in the fourth Diagnostic and Statistical Manual (DSM-IV), published by the American Psychiatric Association. The New York Times today published a report of a study claiming to show links between the authors of DSM-IV and pharmaceutical companies. The report stated,
The researchers found that 95 — or 56 percent — of 170 experts who worked on the
1994 edition of the manual, called the Diagnostic and Statistical Manual, or
D.S.M, had at least one monetary relationship with a drug maker in the years from 1989 to 2004. The most frequent tie involved money for research, according to the study, an analysis of financial records and conflict-of-interest statements.
Honestly, I'm not surprised or upset by the relationship. DSM-IV is published by psychiatrists for use by psychiatrists. It reflects a medical model of mental illness, and most of the experts who work on it are researchers in the biological side of treatment. Most of psychiatry is conducted drug treatment. Psychiatrists prescribe medication. Psychologists, social workers, psychotherapists and counselors conduct psychotherapy. A few psychiatrists still dabble in psychotherapy, but they are a dying breed.
Not surprisingly, then, DSM-IV works fine for medical management of mental illness. It stinks as a diagnostic tool for psychotherapy. Let me show you how it works. A person is diagnosed along five "axes:"
I. Clinical disorders
II. Personality disorders or mental retardation
III. General medical conditions
IV. Psychosocial stressors
V. Global Assessment of Functioning
Axis I disorders correspond to depression, anxiety, and other problems that we normally treat (and are advertised on TV). Axis II refers to personality problems that are long-standing. (Why personality disorders and mental retardation are linked is beyond me.) Axis III details medical status. It's important to know this, as many medical illnesses may manifest the same symptoms as depression or anxiety. Axis IV describes psychosocial stressors in very general terms. Axis V describes a person's level of functioning with a 0 to 100 scale.
So, for example, a person might have the following diagnoses:
I. Major depressive disorder, moderate, recurrent
II. Borderline personality disorder
III. No diagnosis
IV. Problems with the primary support group
V. Current GAF 57
There are myriad problems with this scheme. First, the use of the term "axis" implies that each axis is independent from the others. Nothing could be further from the truth. People with personality disorders, for example, are more likely to have anxiety and depressive disorders than others without personalty disorders.
Second, we don't really know what a "disorder" is. In most cases, there is evidence of both psychosocial and biological causes for a client's complaints. Both psychological and biological treatments are effective for the same "disorders." So, what are we really treating?
Third, this scheme doesn't describe the quality of the client's life very effectively, and that's what we really deal with in psychotherapy. Axis IV, where this should be placed, is very general, and poorly delineated. "Problems with the Primary Support Group," covers a lot of ground, from arguing with your wife to repeated sexual abuse of a child.
Fourth, assessment of these disorders remains rooted in the clinical interview. We've known since the 1950's, with a book by Paul Meehl that clinical interviewing is not very reliable. Unfortunately, psychologists, who are the true experts in assessment, have dropped the ball entirely. We have not generated the kind of data necessary to add psycosocial assessment to the diagnostic manual.
So, why do we need diagnosis at all? We need it to describe what we're treating. We need it to organized our research into better treatment methods. So as a result, we limp along with the diagnostic manuals as written. Hopefully, the next one will be better.