Trouble in Mind: An Unorthodox Introduction to Psychiatry

Appendix A: The Official Version: A Guided Tour of the DSM

Appendix A The Official Version: A Guided Tour of the DSM If the standard approach to psychiatry provides a map of the human-made boundaries that define diagnostic entities, this book has offered the corresponding topographical map. A topographical map portrays mountain ridges, rivers, valleys, plains, and other aspects of nature. Some of these features comprise the borders between states and countries, sometimes they are contained within the borders, and sometimes they cut across the artificial borders. In the topographical map of the mind portrayed in this book, some phenomena are contained within a single human-made diagnostic construct, some define a diagnostic construct, and some cut across diagnoses. If one is to make use of the topographical map in real applications, one needs to be familiar with the human-made boundaries, whether or not they reflect nature. When a highway builder aims to build a highway across several states, in addition to the features of the terrain that concern the road engineer, the builder must be aware of state and local laws in order to obtain the proper permits. For the same reason, in order to treat patients it is essential to know something of the official diagnoses, whether or not they represent valid constructs . Figure A.1 suggests how part of a topological map of mental illness might look. Thus, this appendix provides a brief guide to the human-made boundaries of mental illness now in use, to link the topographical map of mental function, as laid out in the main text, to the practicalities of research and clinical work. It focuses on the facts and factors that help to define these diagnostic entities. Note that in this appendix diagnoses are given unequal attention. The amount of space given to the diagnoses selected for description in this appendix is a function of the public health signi ficance of the diagnosis, its complexity, and its associated controversies. A.1. What Is a DSM Diagnosis? Psychiatric diagnosis is based on collective opinions about patterns in the clinical presentations, course of illness, and treatment responses of patients. Because psychiatry uses a common reference for diagnosis—the Diagnostic and Statistical Manual of Mental Disorders (DSM)—patients who have similar patterns of signs and symptoms are reliably given the same diagnosis by clinicians anywhere and in any setting. However, in the absence of definitive tests of the biological basis of disorders, there is no way to validate a diagnosis in a given patient, nor is there a way to prove the integrity of the diagnostic definitions that lump and split clinical problems into a set of conventional clinical diagnoses. 202 Appendix A A diagnosis can be thought of as a shorthand label for a pattern of signs and symptoms associated with a patient’s clinical problems. Clinical and epidemiological investigations based on these pattern definitions have yielded valuable information to inform predictions about a patient’s likely prognosis and treatment response. So, while the most important considerations in the assessment of a patient are the patient’s signs, symptoms, and problems, it is useful to be able to assign a name to the patterns observed and to identify treatments that are likely (compared to placebo) to be helpful . There are hundreds of diagnoses in the current version of the DSM, and thousands of variations. In this appendix the focus will be on the diagnoses that one is most likely to encounter in general medical or psychiatric practice. Figure A.1. Topographical maps, like psychiatric diagnoses, reflect both manufactured and natural boundaries. The Official Version 203 As of this writing, the fourth edition of the DSM (DSM-IV), established and published originally in 1994 by the American Psychiatric Association, is still in use. The fifth edition is in preparation, and not expected to employ neurobiological concepts to alter the diagnostic criteria or their application (Hyman 2007). It is likely that the DSM-V will serve a purpose similar to the DSM-IV by providing a common reference point to make reliable diagnoses, for the purposes of research and the need to apply a code in order to be reimbursed by insurance companies and governmental agencies. The DSM-IV system uses five axes, all denoting a different aspect of diagnosis. Axis I is the diagnosis that explains the patient encounter. It can be a major mental illness, like schizophrenia or bipolar disorder; behaviors like...