DSM V: Diagnostic Dilema

The media reports controversy regarding the coming publication of DSM V, the manual that tries to categorize mental distress into illnesses. The problem dear Brutus is not in the manual; but in ourselves. I do not mean the patients (or consumers as we are all referred to now days, a promotion of sorts, I guess); no, I mean the professionals who are for the most part caught in the outmoded medical model.

The model works for our familiar physical ailments. If I have high blood pressure, there is a treatment for it. If I have high cholesterol, there is a treatment for that as well. I can add to that arthritis and be treated for all three; no problem. But if I have grief triggered depression, and that is difficult for my narcissistic personality disorder to manage, in part because I’ve begun to think that my would be friends are talking with each other behind my back, I present a problem diagnostically.

While we accept that life style choices affect our physical illnesses and if modified might help manage the diseases: drop the salt, and the cheese and meat, and lose 30 pounds to lessen the load on the knees; we know from experience that there is only so much good those changes can ordinarily do. The illnesses, while perhaps related to each other through our life style are still diagnosed as discreet illnesses.

Despite attempts by the professionals to do so, mental distress does not lend itself to discreet diagnosis. That is the central problem facing the profession at the moment. Once you leave the divide between psychotic illness and  neurosis/personality disorder distress, you are in a quandary. While the medical model continues to have relevance (but not dominance) in the realm of psychosis, the same cannot be said about the rest of the field.

The problem in part comes from trying to cluster certain behaviors into a diagnosis. But complex creatures that we are, we keep slipping out of the box. So time frames are put in place as part of the measurement; depression goes from one category to another depending upon the length of time the depression lasts. But there are a myriad of possible influences on different people at different points in their lives; how can a time line determine a diagnosis? And, perhaps, maybe more importantly, how does it dictate any difference in treatment?

The resolution is complicated by two other factors: our cultural expectation of drug based solutions, and health insurance requirements that have been developed to conform to the medical model.

I do not have a solution to offer; but I do have a transitional recommendation. Clusters of behaviors can be described as roles that we produce to meet the situations we find or put ourselves in. They are triggered by our perception of events and are for the most part almost automatic. Perhaps we would do better to begin looking at these clusters and the situations (internal and external) that seem to summon them.

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