The Diagnostic and Statistical Manual, 4th Edition with Text Revision (DSM-IV-TR) is the Bible for Psychiatrists, Psychologists, Social Workers, and any other providers of mental health services. It is a 943 page monster that contains every known psychological/psychiatric disorder, as well as other conditions that require further study before they can be officially labeled as “disorders.” Any college student who takes Abnormal Psychology will either use the manual directly or take relevant sections from it to aid in their learning. Fortunate graduate students will commit to memory the major sections and philosophy of the text over approximately 5-6 years, while the unfortunate ones will have the book thrown at them in their first week of study with one simple instruction: memorize this before the first semester ends.
In fact, during my postdoctoral training, one of my colleagues claimed to have memorized the entire tome within the first week of graduate school; however, he also claimed that he could “will people out of being HIV positive,” so his words need to be taken with a grain of salt (yes, some shrinks are that weird). Practicing therapists use the DSM-IV-TR at least somewhat regularly to confirm symptoms of disorders that they are considering as a diagnosis.
Few practitioners would question that the manual is flawed in many ways. One of its main problems is that it utilizes a dichotomous approach to diagnosis, as opposed to treating symptoms with degree of impact. For example, in order to diagnosis Major Depressive Disorder, the patient must have “a depressed mood for most of the day, nearly every day…” In other words, you either are depressed for most of the day, or you are not depressed for most of the day. There is no gray area, and very few things in life are black or white:
Dr. Dobrenski: When you say you’re “depressed,” would you say that’s most of the day, nearly every day?
Client: How the hell should I know if it’s most of the day? I don’t measure my mood with a fucking stopwatch.
Dr. Dobrenski: I see. Tell me this: would you say it’s nearly every day?
Client: No, Dr. Dobrenski, it’s one day every four year, just during Leap Year. That’s why I’m here, because I can’t bear to feel sad for one day, 3.1 years from now. Of course it’s nearly every day, Christ! Are you working from some manual or something?
A clinician could gain much more knowledge if the system were designed to provide levels of depressive symptoms in a given day, even if this is simply a 1-10 scale to distinguish the gray, middle of the road areas. This can more thoroughly help clinicians to decide which method of treatment would be best (e.g., medication, therapy, or a combination), and could be used as a rough guide to whether or not treatment is working well.
Another issue with the current DSM is its presentation of most disorders with a colossal amount of symptom variability. Using Major Depressive Disorder again as an example, the patient must show “Five or more of the following (nine) symptoms…during the same two-week period…” This allows for literally dozens of symptom combinations. In other words, if I say to Dr. John that I have a new client with Major Depressive Disorder, Dr. John really doesn’t have a grasp of the symptoms the client is experiencing. This defeats the purpose of the manual.
However, the biggest issue with the DSM-IV-TR is that so many of the disorders are so incredibly rare that the odds of a clinician seeing them actually affecting a person are slim. Conversely, there are fairly common psychological problems that aren’t actually in the book at all.
When I was in training, I saw a lot of college students in the university clinic for relationship difficulties. Because the undergraduate experience is transitory, long-term monogamy and commitment is not the norm. Students would become extremely distressed when relationships did not work out, which was basically always. Poor sleep, lack of appetite, excessive substance use, sad mood, crying spells, poor concentration and many other symptoms would trouble these clients. Many of the students seemed to be suffering from a type of depressive episode, but not exactly. Others showed a type of anxiety disorder but, again, not exactly. One pattern that did emerge was an initial feeling of shock, followed by a sense of betrayal that ultimately led to anger. In heterosexual relationships, this anger was often expressed in therapy with an initial use of vulgarity related to a gender-specific body part, followed by a desire to have something horrific happen to that part. Consider:
Female Client: That fucking dick! I hope he gets Gangrene and his cock falls off!
Male Client: Man, what a Goddamn cunt! I hope that bitch’s pussy freezes shut!
In homosexual relationships, the anger was usually expressed, ironically, as a gay hate term:
Male Client: That bastard cocksucker! I hope that fudgepacker rots in hell.
Female Client: I’m going to cut that rugmuncher if I ever see her again.
Armed with this newfound knowledge of creative ways to express unadulterated hatred and distressed at a lack of “Romantic Jealousy” Disorder, I ultimately decided to take a step toward resolving this problem by studying romantic jealousy for my doctoral dissertation and positing that this syndrome is a diagnosable condition worthy of DSM-IV-TR inclusion. In just a few years, I had seen multiple cases with similar and overlapping symptoms, and the problem clearly caused significant distress for the people involved. I submitted a few papers to psychological journals to support my case, and all were rejected. Professionals in the publishing field said that “we need to focus on conditions that impact a significant number of people, Rob.” This is not the most optimal way to transition from student to professional.
After five years of post-graduate practice, I’ve directly encountered, at most, 20% of the disorders in the DSM-IV. Most conditions seen in general practice can be broken down to: mood, anxious, psychotic, substance abuse, eating disorders, personality disorders and childhood disorders. Within those categories are asinine amounts of minutiae regarding psychological problems that most clinicians will never see. Selective Mutism is a disorder in the DSM-IV-TR. This is essentially a difficulty where the individual has a consistent failure to speak in specific social situations where talk is expected, despite speaking in other situations. The DSM-IV-TR reports that this condition occurs in less than 1% of patients seen in mental health settings. Not less than 1% of the population; less than 1% of people who are receiving mental health services. I’ve already seen more cases of romantic jealousy (which doesn’t exist,) in five years of practice than the entire world will see of Selective Mutism.
Another example is Pica, the persistent eating of non-nutritive substances for at least one month. In other words, Pica is a problem where you eat things that are not food. For comparison purposes, I’m sure many of you know at least one person who has been devastated when he or she finds out that they’ve been cheated on or when an ex-lover starts dating someone else. Do you know a lot of people who have said, “Man, I’m starving. Oh look, a set of nuts and bolts! Let me just swallow those right now!”? I didn’t think so.
This is not to say that people who are suffering from the more obscure conditions deserve anything less than optimal care. But for the purposes of my practice, I now have a disorder/non-disorder that I’d like to treat, but I’m immediately handcuffed. As a general rule, when I develop a diagnosis for a client, I relay this to him/her and explain what it means. Information is power. The more a client knows about his difficulty, the better off he is:
“Okay David, what you are describing is consistent with what is known as Romantic Jealousy Syndrome. While it is not the most common problem in the world, we do know a good bit about it. Here are some articles that I’d like you to read before our next session. My hope is that it will provide you with information about the problem and how we are going to treat it going forward. You and I will talk about and expand on what you’ve read next week.”
This isn’t going to happen, because there isn’t a diagnosis, and therefore there is limited interest in discovering more about it, all while my dissertation collects dust on the bookshelf. There is the occasional piece written up in a journal on “Jealousy as a Syndrome?” or “Thinking about Jealousy as Obsessive-Compulsive Disorder,” but they are few and far between. My publishing colleagues have, in essence, shut my work out of the ivory tower, leaving me jaded and the clients with less than optimal care. This is an example of a tangible rift between academic psychologists and practicing ones. The former generally see the field as a relentless pursuit of discovery and publication, while sometimes missing the relevance or lack thereof of their subject matter. Knowledge for knowledge’s sake is the unspoken mantra, even if it means pouring money into “Bird Behavior,” a real journal that is part of the American Psychological Association’s journal database. I am not against Ornithology as a science, but I am opposed to an association funding it when the organization itself is based on the study of people. Many researchers will point out that studying birds is “comparative psychology,” meaning that information learned about animals can be used to infer knowledge about humans. But should the direct study of humans take a back seat to studies done on animals for mere inference?
Practicing psychologists, in contrast, generally read journal articles or attend seminars to gain practical, hands-on knowledge and techniques to help their patients. They see research as a means to an end. Many of these practitioners don’t care about the finer details of a study: how it was conducted, what statistical analyses were used, did the researcher debrief all participants upon the study’s conclusion? They just want to know how, if at all, this study is useful in the treatment of psychological conditions. Can your study help my patients? If not, go away.
In reality, most psychologists carry a little bit of both philosophies. Unfortunately however, the academic psychologists make the decisions on what makes it into the field’s journals, whether they work directly with patients or not. Unless the field starts to swing in the practitioners’ direction a bit more, we’re going to continue to have a lot of relatively useless knowledge out there. Or maybe just an exorbitant amount of smarts about how birds walk. We can infer a lot about the human mind from studies like that. Or at least, that’s what I’m told.