Duncan Gill, MD
Johnny: a DSM Diagnosis Dilemma
Updated: Nov 2, 2021
Mom: “Johnny has been looking depressed at home and stays in his room. He doesn’t do his schoolwork. He sometimes has panic attacks and either can’t or won’t go to school – I can’t really tell which. He also has a really bad attitude.”
“Oh, and he’s been diagnosed with Major Depression, Panic Disorder, ADHD, and Oppositional Defiant Disorder. The doctor thinks he might be developing borderline personality disorder too.”
Sitting in my office is a well-meaning, anxious mother who is truly worried about her son. Next to her is Johnny, who looks like he’d rather be sitting in a dentist’s chair.
Me: “Okay, Mrs. Smith. Does Johnny have a therapist?”
Mom: “Well, he had one, but he refused to go back after one meeting. He’s had a few before that but never seemed to connect with them.”
Me: “Does he take any medications?”
Mom: “Yes, I forgot the list, but he’s on four of them.”
Me, to Johnny: “You think the meds help you at all?”
Okay, we are running into “DSM Laundry List Syndrome”.
The problem isn’t so much the list of five diagnoses (which is overwhelming in and of itself), but the fact that mom believes that these five diagnoses mean more than they do. She thinks – and probably has been led to think – that this list of labels contains all the critical information we need to solve Johnny’s problems.
If Johnny has five diagnoses, does it mean that Johnny needs five different types of treatment? Five different medications? Five different types of therapy? Does a list of five diagnoses mean that Johnny is five times as impaired than if he had just one diagnosis? At the very least, in this particular case, a list of five diagnoses makes Johnny five times as angry with his mother and five times less likely to talk to therapists. Which ends up making my job more difficult.
Let’s get some context here. The DSM, or Diagnostic Statistical Manual, is considered by many (importantly, including insurance companies) to be the “bible” of psychiatric diagnosis. In the DSM you will find names and codes for all the possible diagnoses from Antisocial Personality Disorder to Voyeurism. All of Johnny’s current diagnoses are in there. The DSM diagnostic criteria consist of a series of checkboxes for various symptoms. Check enough of the boxes, and you qualify for a given diagnosis.
The DSM has pluses and minuses. On the plus side, it can be viewed as a valiant attempt to establish a common language for clinicians. The idea is to standardize diagnostic criteria so treatment providers are using the same words to describe the same things, rather than everyone having his or her own definition for different psychiatric conditions. You need to have some kind of standardization, particularly if you are going to conduct research. You have to be able to decide, for example, who has bipolar disorder and qualifies for the study, and who doesn’t. And research has been critical to developing fantastic new treatments for psychiatric conditions. So, to that extent, we need a DSM, or something like it.
Now for the minuses. The diagnostic criteria are decided by committee. A group of psychiatrists gets together and debates what should be a diagnosis, what shouldn’t, and what the criteria for each should be. Clinicians have varying degrees of confidence, shall we say, as to how good a job the DSM does at describing any given diagnosis. In my opinion, it does a good job for some diagnoses and a not so-good-job for others. A lot of folks also think the “checkbox” approach is quite limiting. I agree. By the way, the DSM goes through changes every few years (see the picture above), and some diagnoses disappear and new ones magically materialize based on the current zeitgeist of psychiatry.
To be fair to the DSM and its creators, it is important to realize that – as of 2021 – we have exactly zero blood tests and exactly zero brain scans that can accurately determine psychiatric diagnosis. And “standardized tests” and rating scales are only as good as the clinicians interpreting them. Suffice it to say the brain is really, really complicated. The best way to make a diagnosis is to sit down with a patient and interview them.
Let’s get back to Johnny. His list of five DSM diagnoses doesn’t tell us anything about his circumstances. Nothing about his temperament, home life, parenting, or stage of maturity. These factors – let’s call them “developmental” factors – might account for a lot of Johnny’s problems, or maybe even all of them. DSM diagnoses are an attempt to standardize, which is good for a lot of conditions, but developmental factors don’t standardize well, and just end up being omitted altogether.
So, it’s possible Johnny has a real, biological “Major Depressive Disorder,” but it’s also possible his parents are going through a divorce and he’s just having a rough time. The DSM won't distinguish between the two, and of course the approach to Johnny's treatment would be different for each.
The DSM checkbox approach can also be taken too literally. Sure, Johnny technically may “qualify” for all five diagnoses, but is that the most useful way to look at things? Does this mean he truly has five different conditions? Or is he simply depressed, gets anxious and angry when he has to go to school, and doesn’t pay attention in school because he’s got too much else on his mind?
Don’t even get me started on “Oppositional Defiant Disorder”….
Sorry, I can’t help myself. I think Oppositional Defiant Disorder is a prime example of the DSM’s going off track. Kids are oppositional for a whole bunch of reasons. They get tired of being told what to do, they have unreasonable adult figures in their lives, they are immature, they are trying to demonstrate to their friends or their parents or themselves that they are independent and don’t take crap from anybody. Being oppositional is not a “disorder”. It’s an adjective.
Thanks for indulging me there.
All this is a long way of saying sure, DSM diagnoses have some utility, but my goodness we need to understand their limitations. Excessive reliance on them sometimes overcomplicates relatively simple problems, and sometimes it misses the boat entirely on developmental problems.
Back to Johnny.
Me: “Okay, Mrs. Smith, how about we start from the beginning?”