CAUTION! Who Should Be the DSM-5 Diagnostician?

“The proper use of these criteria requires specialized clinical training that provides both a body of knowledge and clinical skills.”

How many of us psychiatrists recognize this statement? Or, is it like the fine print that we often gloss over in our everyday contracts and hope it doesn’t cause us trouble at some later time?

If you did not know, it is actually from the brief Cautionary Statement (p. xxvii) of our current DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition the (1994). It is also in its predecessor, DSM-III-which came out in 1980-but not in DSM-II-which came out in 1968.

You may ask, “So what?” Actually, I think the implications have been immense for the profession of psychiatry, and perhaps for patients. If we pay more attention to these comments and to their evolution, we might well conclude that they have had a major negative impact on the identity of psychiatrists.

DSM-II

Please bear with me as I turn back to DSM-II. There is no “Cautionary Statement,” but instead, a parallel commentary in the Foreword. It does not directly say who can officially use the manual but implies it is psychiatrists:

“The Committee has attempted to put down what it judges to be generally agreed upon by well-informed psychiatrists today. In selecting suitable diagnostic terms for each rubric, the Committee has chosen terms which it thought would facilitate maximum communication within the profession and reduce confusion and ambiguity to a minimum.”

Then, in “Section I: The Use of This Manual: Special Instructions,” it goes on:

“. . . the opportunity to make multiple diagnoses does not lessen the physician’s responsibility.”

Since psychiatrists are physicians, the responsibility must have been intended to be ours.

DSM-III

When we get to DSM-III, who is qualified to be a diagnostician is much more ambiguous. In essence, it allows anyone with mental health training to claim they are knowledgeable enough to make a DSM diagnosis and get paid for it. It does not say that “specialized clinical training” means 4 years of medical school, followed by 4 years of internship and residency training-even though many diagnostic categories are laced with medical considerations. It also does not specify what “body of knowledge and clinical skills” are adequate. Given the common perception that there is a “cookbook” approach to DSM-IV, it may seem that just reviewing the criteria and asking if a patient has the symptoms would be easy and adequate.

It has been hard to find out how this fine print came to be, but we can note that DSM-II came out at the beginning of the community mental health movement. Before then, psychiatrists were still clearly the leaders in the field. As community mental health centers developed, multidisciplinary teams emerged as more outpatient clinicians were quickly needed. While there was much advantage to pooling the specific knowledge base of various disciplines, as we tried to indicate in the book I co-edited, A Clinician’s Manual on Mental Health Care: A Multidisciplinary Approach (Menlo Park, Calif: Addison-Wesley; 1982), there were also potential drawbacks. Roles often became blurred, especially regarding administrative, diagnostic, and psychotherapeutic functions. Paraprofessionals were added. Some teams went so far as to become egalitarian.

DSM-5

By 1980, when DSM-III came out, these changes may have been reflected in who could-or should-use the manual. Because it was bought by so many more clinicians, it became a best seller for its publisher, the American Psychiatric Association. This is recalled in a question the American Association of Community Psychiatrists gave to our current candidates for APA office on the controversy about DSM-5’s development. One answered:

“DSM-IV, imperfect as it is, has been an extraordinary moneymaker for APA. DSM-5 also is likely to make a lot of money, which we certainly need! . . . If there were numerous scientific breakthroughs we could better justify moving fast.”

Much has been written about DSM-5, especially in Psychiatric Times, including concerns about transparency, diagnostic criteria, timing, and the influence of Pharma. The developmental group is now entering the stage of inviting comments from psychiatrists at large. Up until now, I believe virtually nothing has been discussed about who should use it. If we gradually obtain neuroimaging and/or genetic markers to improve diagnosing, it would seem that the diagnostic process will become even more of a medical one, most suitable for psychiatrists.

This, then, is a unique opportunity to address the crisis of the identity, authority, and compensation of psychiatrists. I would therefore caution against the same Cautionary Statement. Instead, I would say something like:

“This diagnostic manual is derived mainly from the expertise of psychiatrists. Given the importance of general medical knowledge in making an accurate psychiatric diagnosis, the appropriate use of this manual is for psychiatrists to certify the official diagnosis. The exception would be those who are specially trained and supervised by the American Board of Psychiatry and Neurology.”

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A RESPONSE FROM CHARLES HUFFINE, MD

I have grave difficulties with the implications that psychiatrists have some special knowledge about diagnoses due to our tenure in medical school and a residency.

When psychiatrists are designated as sole diagnosticians, with all the implied medical pretense, it serves to isolate us in a state of “hyperspecialization” wherein we no longer have authority in the psychosocial aspects of the mental health field. It is painfully obvious in community mental health settings where 90% of the action is with mental health professionals from other fields. No doubt many are under, or poorly trained-but I would contend that many of us are, too. We get chained to the pillbox! A mind-numbing place to land.

My respect goes to experienced, well-rounded mental health professionals who have worked with difficult clientele, have faced tough decisions, have had to take responsibility in a crisis, and have had some patients complete suicide in their care. No, we are NOT the only ones. These are my colleagues, those in whom I place my trust, those who I know can use our diagnostic tool while at the same time still thinking for themselves. I trust those who do NOT cookbook diagnoses or use fancy but sterile scales, who actually get to know a new patient/client/consumer in the room with them, and who can engage them, drink them in, and feel the symptoms, have an organic notion of the diagnosis even before they name it. I respect those who have a healthy skepticism regarding the worth or validity of those diagnoses that are really not diagnoses such as Conduct Disorder, Oppositional Defiant Disorder, and even Antisocial Personality Disorder (forgive me for airing my C&A psychiatrist pet peeves.) I trust those clinicians who can smoothly integrate a good feel for cultural issues, for social factors such as poverty, and are not afraid to stare in the face of horrific abuse and subsequent trauma. I value those who don’t see “explanations” in neuroimaging rather understand such images as only the physical correlates to what we already know very well from clinical knowledge.

Many psychiatrists achieve my respect for this more comprehensive view of our field, but I have found that my colleagues with such comprehensive understandings frequently include other specialties (ie psychologists, experienced social workers and other masters level mental health professionals, and occasional occupational therapists [or even once a “clinical” anthropologist]). I trust these to use OUR DSM tools expertly and, even more important, have their diagnoses rest on an elegantly conceived formulation of what is going on with the patient/client.

It is true that (occasionally) these individuals have deferred to psychiatrists when clear medical problems were effecting brain function; but even in these cases, there is a role for neuropsycologists and OT’s who have had long experience in rehab units and may know more of the medical significance of the behavior or symptoms of a patient than most psychiatrists.

Our guys wrote the book, actually a narrow subset of “us guys,” mostly academic psychiatrists, wrote the book. Do they convey in the text all the wisdom in the mental health field? No they don’t! But they do have the corner on the market of how we get paid-a little string of numbers from our book attached to the diagnoses given the patient matched with another string of numbers indicating what we did for our patients seals the deal, money flows to our offices, hospitals, clinics, etc., and everyone is happy. It is disingenuous to say that only a psychiatrist can provide that service-we can’t, won’t, and shouldn’t. Nevertheless, the DSM-5 will guarantee a continuation of the big bonanza for the APA-it will make all of us get the $$$.

I don’t mean to be too cynical just dealing with practical reality and the world as it is. Lets just not be too self-congratulatory about our very flawed but useful product. Let’s definitely NOT claim a corner on the diagnostic market lest we appear naked and ridiculous. Let’s buck the tide and seek a practice where we can be the wise, experienced, broadly trained clinicians who have EARNED the ability to use the DSM wisely.

           ************************Dr Moffic replies to Dr Huffine:

Thanks, Dr Huffine. I obviously disagree. The DSM-5 will make the APA a lot of money, but it won’t enrich psychiatrists, at least as long as other disciplines can also make official diagnoses. And, if our medical background doesn’t matter more, just give psychologists, et al, prescription privileges.

DR. RIOLO WEIGHS IN

If  Dr Moffic wrote his letter regarding limiting who can make a DSM diagnosis 10 or even 5 years ago rather than this month, I would have led the ranks of many of my non-physician mental health providers in protest.  For years, I fought for the right for us to use the DSM, obtain third party reimbursement, and practice independent of the medical profession.

However, I am now not quite so sure. The problem is that-since my retirement from clinical practice-I have become a consumer advocate and have found numerous problems in the way DSM is used, which harms patients in the long run. Many mental health professionals I have encountered do not use the DSM as it was intended and often don’t believe it is reliable, valid, or useful.  They may have a point-however, despite their skepticism regarding DSM’s accuracy or utility, they continue to diagnose people, giving them labels which may or may not fit. Such incorrect diagnoses can be harmful in many ways.

Some providers are quietly open in admitting that they use the DSM, only because it is the only way to get third party insurance to pay for their services . Some admit to picking a diagnosis without scrupulously seeing if the criteria are present, while others will “up-code” or increase the severity of the diagnosis simply to get insurance companies to pay for more treatment.

Now, of course, psychiatrists are not necessarily immune from these practices. However, when one considers mental health practitioners, all claiming the right to diagnose mental illness, reducing the numbers who legitimately are able do so will be a safeguard to patients and help minimize abuse.

John A. Riolo, PhD
Civil Discourse BlogThe InsiderYour Advocate OnlineLaw and Ethics In Mental HealthListen to The Insider Podcast Series

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READER RESPONSE, BY JARED DeFIFE, PhD:

I hope to convey my response to your blog with professionalism and a great deal of respect for your ideas, credentials, and body of work in the field.  At the same time, I am astounded, disappointed, and, dare I say, to a significant degree, offended by your remarks.

My reaction is primarily to your suggestion that a Cautionary Statement be written along these lines: "This diagnostic manual is derived mainly from the expertise of psychiatrists. Given the importance of general medical knowledge in making an accurate psychiatric diagnosis, the appropriate use of this manual is for psychiatrists to certify the official diagnosis. The exception would be those who are specially trained and supervised by the American Board of Psychiatry and Neurology."

Indeed, the DSM is produced by the American Psychiatric Association.  At the same time, such a statement strikes me as flagrantly dismissive and neglectful in recognition of the significant contributions of psychologists (among other disciplines) to the research and criteria upon which the DSM is built, not to mention the multidisciplinary approach to mental health care in the community.  The DSM is a multidisciplinary creation, and should be utilized in that same spirit.

As a personality researcher, I will speak to the Axis II diagnostic system, although the contributions of psychologists to Axis I are just as intricately linked to the manual. The proposed criteria for personality disorders (which I hope the classification of personality disorders is recognized as useful to the mental health field) are not only based on a body of research conducted by psychologists in coordination with psychiatrists, but are in fact actually written by psychologists (some of whom I work with).

I would never suggest that a diagnostic system for mental illness be used without advanced clinical expertise. At the same time, I am nearly speechless at the level of disrespect to a large body of people who have contributed extraordinary efforts and lifetime career achievements to this field.  It is my profound hope that you would reconsider if not just your position on this issue, but at least your presentation of them to the greater community

Jared DeFife, PhD
Research Scientist
Emory University
Departmen tof Psychology
www.psychsystems.net

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Dr Moffic replies to Dr DeFife:

I appreciate your feedback and am not surprised by it. In fact, I would expect somebody from psychology or social work to protest strongly what I have said.

I'll try to justify my reason for doing this a bit more, given the space limitations of the blog. Indeed, I have always worked in, or led, multidisciplinary clinics and have had some of the experiences of Dr Huffine, as he described in his comments. In the book I co-edited, A Clinician's Manual on Mental Health Care: A Multidisciplinary Approach, I expressed concerns that linger today, and the following are some of them:

1. The diagnostic skills of many leave a lot to be desired, and the current DSM-both the "cookbook" approach and the lack of criteria for the diagnostician-are the major problems. Medical contributions are more often missed by non-psychiatrists, though I think primary care physicians are inadequately equipped to use DSM for other reasons.
2. Psychiatrists are losing our identity.
3. The manual is published by our APA; it is not a multidisciplinary product, although it could be. For that matter, psychologists could put out their own diagnostic manual. It might be interesting to compare both. Certainly, a greater usage of psychological testing and psychological research criteria might produce a different sort of manual.
4. Virtually all the heads of the committees working on the different diagnoses for DSM-5 are psychiatrists, though psychologists do contribute.
5. Part of the motivation for leaving the criteria so open for being a diagnostician are financial; DSM manuals have made the APA a lot of money.
6. How would you operationalize "advanced clinical expertise"?

It's striking to me that, at least as far as I know, there have been no studies comparing the diagnostic skills of the different disciplines. I had wanted to do so years ago when I began to lead a large capitated system, but was overruled for financial reasons. Wouldn't this be a good time for some large organization to conduct such a study?