We Are All DSM5 Diagnosticians-We Are Not All Physicians

Another lifetime ago-just after leaving residency-I took a job as a psychiatric consultant at a large, university mental health center. Had I known the poisoned politics of the place, I would have headed for someplace safe-like, say, Afghanistan.

The center was directed by a psychologist, who, nominally, was my boss. But the mental health center was a subdivision of the “Student Health Service,” which was run by a crusty old internist who refused to let the psychologists hospitalize a student in crisis, without first obtaining “medical approval.” He wasn’t much more respectful of my role, as “Consulting Psychiatrist,” and once muttered, within earshot, “A psychiatrist is nothing but a damn psychologist with ‘MD’ after his name!”

I left the job after 2 frustrating years. My time wasn’t wasted, though-I learned a lot about psychopathology in the college-age population and gained considerable respect for clinical psychologists. (My respect for psychiatric social workers evolved much earlier-the legacy of my mother, Frances Pies Oliver, ACSW, and her wise tutelage).

My time at the university clinic also prepared me for the kinds of disagreements we are now facing, as psychiatrists, psychologists, and other mental health professionals weigh in on the DSM-5, and who is “qualified” to be a DSM-5 “diagnostician.” As recent blogs by respected colleagues like Dr Moffic and Dr Carlat demonstrate-and as comments by Drs Huffine, Riolo and other fine clinicians reinforce-this is a hot-button issue. Though distinct from the substantive controversies surrounding the proposed DSM-5 criteria, the argument over who “owns” DSM-5 diagnosis is clearly related to the nature of the classification itself.

So let’s step back for a moment and ask a fundamental question: what is “diagnosis”? The word may be understood through its Greek origins: dia- means “across” or “between”; gnosis means “knowledge.” So diagnosis may be understood as “knowing the difference between” condition “A” and condition “B.” Diagnosis is therefore an inherently relational term: You cannot “know” that a patient has schizophrenia without knowing that he or she does not have another condition that could account for the symptom picture more parsimoniously (“Knowing,” of course, is a tad grandiose-I really mean something like, “having a very high degree of factually-based confidence”).

This is one reason that the recent DSMs have incorporated exclusionary criteria for the principal (and usually, most serious) psychiatric disorders. Thus, in the DSM-IV criteria for schizophrenia, the “E” criterion states, “The disturbance is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition.” Similar exclusion criteria are built into the DSM-IVconstructs of major depressive and manic episodes. To diagnoseschizophrenia or mania, therefore, is to know the difference between these states and, for example: Wilson’s Disease; complex partial seizures; phencyclidine or cocaine intoxication; corticosteroid toxicity; CNS lupus; and a tumor of the left temporal lobe.

Is it “elitist,” parochial, or merely defending one’s “turf” to claim that only physicians, among mental health professionals, have the requisite training and expertise to make such determinations? I believe the answer is no. Is it elitist to claim that only physicians-especially psychiatrists-can contribute in valuable ways to a patient’s DSM-5 diagnosis? I’d shout “Yes!” to that one.

As a psychiatry resident, I learned valuable diagnostic wisdom from a number of my psychologist supervisors. (Personal disclosure: My sister is a psychologist and she occasionally reads what I write). Psychologists will often pick up personality traits and psychodynamic issues that I sometimes miss; and neuropsychologists, in particular, are better than I at picking up subtle deficits related to regional brain dysfunction. Psychiatric social workers are also better than I am at delving into the patient’s family systems issues, social supports, economic pressures, housing problems, and marital stressors that are supposed to be coded on that woefully neglected, multi-axial stepchild, Axis IV. (Disclosure #2: My wife was trained as a psychiatric social worker). And let’s not forget about the clinical nurse specialists, physician’s assistants, psychiatric nurses, and mental health aides-all of whom have valuable knowledge and experience to contribute.

But before we all break out into the proverbial chorus of “Kumbaya,” let me be clear: Respect for the knowledge and wisdom of other professionals does not mean creating a false “democracy” of interchangeable diagnosticians. Ultimate responsibility for the patient’s diagnosis will inevitably reside with the identified attending physician. And by “inevitably,” I mean something like: You, as the attending physician and “Captain of the Ship,” will be the one hauled up in front of the judge and jury to explain why Mr Jones’s temporal lobe tumor was called “paranoid schizophrenia” for 4 years-until Mr Jones keeled over dead, from elevated intracranial pressure.

Does this mean that psychiatrists are infallible diagnosticians, or that we routinely perform up to our own standards of medical training? Alas, no. Too many psychiatrists, in my view, have forgotten how to inflate that blood pressure cuff to check for postural hypotension; and too many of us prematurely reach a “psychiatric” diagnosis before obtaining routine laboratory tests, such as thyroid functions. To this day, I am still haunted by a case of neurosyphilis I missed many years ago, in a hospitalized patient diagnosed with chronic schizophrenia.

We can all do better. We are all “diagnosticians.” And we can all contribute in important ways to the DSM-5 diagnostic process. But we are not all physicians.

Suggested readings:
Simon RI, Shuman DW. Clinical Manual of Psychiatry and Law. Arlington, VA: American Psychiatric Publishing, Inc; 2007. [See in particular the concept of respondeat superior, pp. 25-26].

Pies R, Summergrad P: Dementia, Delirium and other Cognitive Disorders. Chapter in Wiki-Text, available at: http://en.wikibooks.org/wiki/Textbook_of_Psychiatry.