Sumit Anand, MD
The Diagnostic and Statistical Manual of Mental Health Disorders, 5th edition (DSM), is clinicians’ tool to form a diagnosis. I have seen plenty of DSM labels stacked together when encountering new patients. They say: I have ADD, PTSD, MDD, BPD, Bipolar and SAD. This tells me more about our current diagnostic system and how it is being used than anything it does about the actual patient. In short, it’s quite a mess. It requires untangling these DSM-5 diagnoses so there’s more clarity.
By the time I encounter them, patients are already confused, annoyed, and unclear about what the label means, let alone why they are taking so many different pills at once. Inevitably, they turn to Dr. Google. However, they just become more drenched in what I call information vomit. It’s a plethora of words, rehashed criteria, and endless lists of side effects and warnings about suicidal thoughts. Enough to give anyone anxiety and even panic.
How Do We Clean Up DSM-5 Diagnoses?
Is it possible to have several disorders at once? Yes. However, as the list gets longer, each diagnosis requires closer scrutiny to ensure it is not “better accounted for by” (that’s DSM guidance) one of the other listed diagnoses. I have not seen this happen as often as it should in my decades of practice. The opposite occurs, namely, the diagnostic list growing longer and longer.
I interpret this phenomenon in several ways. The first is that healthcare practitioners may not use the DSM as it was rightly intended. It takes effort to sift through. Our current healthcare system in the United States isn’t geared to do that thoughtful, discerning practice.
Instead, practitioners must check a box to ensure a billing code is generated. It’s not for want of trying, but because of how the system conditions clinicians to practice mental health: checking boxes and trying to put the square peg of what they are seeing into the round hole of a rigid diagnosis, which inevitably leaves them unsure when they have so little time per patient.
The second is the inherent design of the DSM-5 diagnoses, with its lists of criteria. Clinicians were never trained to think of diagnoses as lists. Behavioral healthcare providers tend to resort to the use of “unspecified type” because the criteria that have to be met for a disorder don’t qualify for any of those listed in the DSM.
The cluster of symptoms gives them an intuitive feel of a syndrome. This includes the life stresses that may have led to symptoms, how the patient experiences something and the overall impact on their life.
Getting the Right Diagnosis
The DSM does not focus on these causal elements. It has lists of symptoms it has arbitrarily decided are a diagnosis and which are divorced from their causes. That’s not how it works in real life. Then every 7-10 years or so, criteria are added or deleted by a committee based on trials of patients in the field, again using criteria-based checklists in a dry, statistical way of distinguishing diagnoses.
If you ask most clinicians, they will tell you that diagnoses often merge. I have frequently seen symptoms of Generalized Anxiety Disorder alongside Social Anxiety Disorder, Panic Disorder, and even PTSD. All of them are characterized by exaggerated fearful reactions, hypervigilance, avoidance/escape behaviors, and anxious anticipation.
This tells me that the patient has developed an anxiety consciousness or predisposition that cuts across these artificial diagnoses and likely has roots in past traumatic experiences. In addition, I know that medication with the ability to increase brain serotonin transmission will be most effective for all these symptoms in the long term.
How Multiple DSM-5 Diagnoses Should Be Handled
It is possible to have multiple diagnoses. But that requires detailed history taking, which is often not performed. This has led to the other unsafe practice I commonly see of piecemeal prescribing: trying to treat each disorder as though it were a single symptom.
There are approaches to diagnoses than can be subject to historical swings of the pendulum. Over the decades, much debate has occurred as to whether diagnoses should be minimized to as few as possible by lumping them together or conversely split into subtypes or even different disorders. The current DSM system favors the latter. For that reason, we have seen an explosion in the number of psychiatric diagnoses over successive iterations of this internationally used manual.
I think that is a mistaken approach. For example, although clinicians are trained to address sleep complaints by considering it as part of the big picture manifestation of an anxiety or depressive disorder, they are now being increasingly encouraged to think of insomnia disorder and prescribe a sleeping pill rather than treat the underlying issue.
A symptom in and of itself is never a diagnosis. I try to ascertain what else is going on in their life, what susceptibilities their childhood may have rendered them, and what other symptoms the patient is reporting. Then I try to connect the dots between the different symptoms, their timing, and context, thus coming up with the most obvious diagnosis that explains the patient’s symptoms.
As I get to know the patient better, the context of their life, their use of substances, and with the perspective of time, I will either revise or consolidate my original diagnosis. Based on one or two symptoms, I avoid jumping to one particular diagnosis.
The Art of Practicing Psychiatry
What works for me in coming to a diagnostic conclusion is simply letting the patient narrate what they are going through, with me asking a few clarifying questions to help me better distinguish what it is from what it is not. When one starts to take into account the associated life stresses and the onset, pattern, and severity of symptoms, the story starts to take shape. This overarching story says it all because it will resonate with the pattern of the patient’s symptoms and their responses to them.
Nobody wants to feel like someone is just checking boxes when it comes to diagnoses. It feels dehumanizing because it is! Just because the computer is an everyday part of our lives, it should not dictate how we think about psychiatric dysfunction, especially when it does not consider what comprises the totality of one’s own life. I make extra effort to listen through the noise and fog of symptoms to what the patient is trying to tell me. This is the art of practicing psychiatry: a universe away from the endless diagnostic checklists, billing, and diagnostic codes, and something that requires a more clinically intuitive sense of what is wrong. A bit like the art of using a stethoscope–only in the case of clinicians, it should be their listening skills.
Throughout the first evaluation, it will become evident how and why the patient is suffering, what the tangible impact on them is, and what type of relief they are seeking. Why does that sound like basic humanity and common sense? I suspect that our current system doesn’t compute that part.
Finding What’s Necessary at Insight Recovery Centers
With all the noise and clutter of diagnostic confusion, what hopeful adage can I leave you with? Rather than asking patients to “talk to your doctor,” we should be asking doctors to rely more on their clinical intuition and listen more to the patient.
You can learn more about DSM-5 diagnoses by calling Insight Recovery Centers at 703.935.8544.