Understanding Psychiatric Diagnoses as Conceptual Tools
People often ask me to determine whether they suffer from a particular diagnosis. In many instances, I have to explain to them that they should take the diagnoses with a grain of salt and focus on what to do to improve their lives or to ameliorate particular vexing problems, rather than wondering whether or not a particular label is appropriate. At times, the diagnosis is essential to determine the safety of or eligibility for a particular medication or eligibility for services. In addition, a diagnostic label is often able to somewhat accurately convey a truckload of information about a person in a simple shorthand that can be distilled into a diagnostic code. In addition, diagnostic categories facilitate scientific research so we can make better predictions about prognosis and treatment. However, determination of the most effective course of action does not always require generating a label-except for the need for a label for insurance reimbursement. In some instances, I have to explain that diagnostic labels are imperfect tools and should not be accepted as gospel. The development of a diagnostic system is a complex and contentious affair. To boil it all down to a simple phrase, just as there is more than one way to skin a cat (or in deference to cats, more than one way to peel a Kiwi) there is more than one way to organize and conceptualize psychiatric difficulties and/or problems in living. Consistent with this, there is more than one diagnostic system. Continue reading to get further into the weeds on this.
There are alternatives to the diagnostic categories of the DSM-5. Just as there is more than one way to organize the clothes in a closet, there are many ways to conceptualize psychiatric difficulties. The current DSM-5 categories will likely be thought of Very Differently in 50 years. Many of the terms will not exist. There may not even be any diagnostic categories.
The National Institute of Mental Health (NIMH) is developing a dimensional approach as opposed to the discreet categories of DSM-5. While the dimensional approach is praised by many, there is concern that the NIMH will privilege biological causation and thus increase the emphasis on psychotropic medications.
In contrast, temperament researchers argue that many childhood problems are best conceptualized as a mismatch between temperament and environment rather than a defect, biochemical or otherwise, in the individual. This perspective of course does not explain all mental illness. From the temperament perspective there is a continuum between temperament and mental illness, with diagnoses often made too freely.
Another theoretical approach, this coming from the great grandchildren of Freud, has produced an alternative diagnostic manual, the Psychodynamic Diagnostic Manual -2. This is sponsored by a group of ten psychodynamic organizations from the US and other nations. It aspires to be a “taxonomy of people” rather than a “taxonomy of disorders.” the diagnostic categories are similar to those in DSM-5. For a technical review click here..
The Power Threat Meaning Framework is a British theoretical approach that eschews diagnostic labels and focuses on what happened to the individual, how it affected the person, how the person interpreted the threat and what had to be done to survive.
The Hierarchical Taxonomy of Psychopathology or HiTOP is a another group of researchers attempting to improve on psychiatric diagnosis by using what may loosely be described as a statistical approach as opposed to the theoretical approach. The HiTOP model begins with broad categories such as internalizing (e.g., depression, anxiety) and Externalizing (e.g., aggression, acting out) and when discrete categories are not readily apparent, using a dimensional approach. A major problem with the discreet categories of DSM is that the person is either in or not in the diagnostic box. The result is that two different clinicians, looking at identical information, may and often do make the call differently.
Each approach may be thought of as a toolbox full of tools, with different tools useful depending on circumstances. The DSM-5 is the tool needed for insurance reimbursement.