Alternate titles:
- The Gang Rewrites the DSM
- Derrick Sychiatric Manual: DSM
- The Blog Post Where Derrick Gets Way Outside His Scope
Talk to any mental health professional about the DSM (Diagnostic and Statistical Manual of Mental Disorders), and you’ll hear a variety of responses. Research-focused psychologists in their academic pursuits might extol its virtues in classifying and categorizing complex pathologies in their attempts to organize randomly controlled trials. Anti-oppression-oriented clinicians will decry the homogeneity and implicit biases of that purple book. But I know you’re all dying to know MY thoughts.
The noble and debatably necessary effort of attempting to categorize, study, and compartmentalize the pathologies listed in the DSM is a fundamentally flawed concept, in my opinion. It is attempting to apply a medical model framework to the complicated topic of mental wellness which fundamentally transcends medical aspects. There are certainly medical/biological aspects which impact our mental and emotional wellness. However, despite the best efforts of researchers and pharmaceutical companies, we’ve yet to fully comprehend the totality of those fancy words in the DSM. There’s no swab that we can look at under a microscope and say “oooh look! A schizophrenia!” No genetic test (although some companies are claiming to have made some progress here) that neatly labels the breadth of pathological psychiatric experience.
So, let’s throw it out! Burn that book, delete those Google drive docs that current researchers are using to build out the DSM-6. Woah, woah, woah. Not so fast. While it might not be a perfect product, the art of diagnosing has its utility. More nuanced, it is how we ascribe meaning and weight to the various labels within. In the wise words of my mentor and former Spring Lake Ranch psychiatrist Dr. FauntLeRoy: a diagnosis is like a suit of clothes. You try one set on, wear it until it doesn’t fit anymore, and then you try on something else. But most importantly, your clothes do not define you.
Branching off that (pun unintended as you’re about to see), I think of diagnoses and the fine art of diagnosing as a tree. We’re all sprouting from the same roots and trunk of our shared human experience. However, some of us might veer off onto different limbs of pathological experience. This simply means that some symptomological phenomena interfere with our ability of function within our environment. Maybe we’ve got some neurotic tendencies (shout out to papa Freud) that jut out from the trunk of our tree and create discomfort as we try to control an uncontrollable existence. Off of that limb, you might see further branches of symptoms related to anxiety disorders, OCD, disordered eating, or personality disorders. There’s often not a clear delineation between these labels, but they’re describing a similar area of the tree upon which an individual might rest.
On another limb, you might find difficulties differentiating between internal and external experiences. These folks might have internal stimuli that are common to a human experience but struggle to compartmentalize into meaningful integration. There might be branches of hallucinations, delusions, depersonalization, derealization, or disassociation.
Continuing further are limbs related to emotional regulation and mood. On some branches folks might cycle up in mood into manic states or slip down into depressive episodes. Or maybe do a bit of both.
But the important part is that these limbs and branches intersect with each other. They aren’t neatly pruned so that parts of the tree don’t contact and interface with one another. Someone can experience intense emotional swings and struggle to integrate internal stimuli into their external world. Or they might have a neurotically predisposed angst that borders on delusional in their attempt to manage anxieties.
In my work on the Ranch, I’ve heard myriad parents express frustrations with the alphabet soup of diagnoses that their children have been given across the gamut of their treatment histories. “This psychiatrist said that my child had OCD, but then the next hospitalization gave him schizophrenia, but now I’m reading the records, and I see schizoaffective-bipolar type. How can everyone be so wrong?” It’s a well-intentioned question and not off-base. This illustrates the complicated nature of psychiatric diagnoses. Maybe each provider isn’t wrong but simply looking at their child on a different part of the tree. The important part to remember is that they are all attempting to help that individual reach a more comfortable part of the tree where their symptoms have less impact on their ability to function meaningfully and individually. To again quote Dr. F, “oaks are not birches are not willows.”
In summation to my hopefully-not-too-confusing analogous tree picture, when we think of those letters and labels in psychiatric diagnosing, I hope we put less significance on the specificity of the label and more focus on the attempts to restore a level of function on the spectrum of human experience. Putting on my reckless speculation hat, I imagine as researchers finalize the DSM-6 (which is intended to be more of a “living document” than previous iterations), we’ll see that several of those strict labels are deconstructed; schizophrenia will be several different diagnoses, our understanding of Autism will shift, depression will have more sub-types, cultural and socioeconomic factors will be more heavily accounted for, and we might see some new pathologies explored. And if/when the DSM people call me (they might have a wrong number since I haven’t heard anything yet), they’ll hear my confused ramblings on tree analogies.
Thanks for reading!
