For over 40 years, therapists have relied on the DSM to guide diagnosis. But what happens when the categories don’t quite match what we see in the therapy room?
I very much enjoyed this read. It’s great to see Ghaemi’s work becoming more widespread. His book on the history - and failings - of the biopsychosocial model is also an insightful read.
I have very mixed feelings about DSM. As a CBT therapist I have found the diagnoses incredibly useful in guiding treatment decisions. Regardless of whether social anxiety disorder or insomnia disorder are valid constructs, the treatments I select look very different for each (e.g. video feedback would not be helpful to the latter whilst sleep restriction would be unhelpful to the former).
I think there is nuance to Ghaemi’s argument, as he’s also very critical of the anti psychiatry movement who contest that no psychiatric diagnosis is valid. He would argue that some are - I think around a dozen or so - like schizophrenia, bipolar disorder, panic disorder, OCD, and PTSD (which he likens to a psychological injury).
He suggests DSM has also caused practitioners to focus on assessing for symptoms (via a checklist) to make a diagnosis, rather than looking for other diagnostic validators like genetics/family history, course of illness, and treatment response.
In fairness to the DSM, it was never intended to be reified in the way it has been. Indeed, in the introduction - which basically no one reads - it suggests that it should be used as a clinical tool, alongside clinical judgement. I think its use in America to bill insurance companies is partly responsible for this.
Finally, the DSM has at least stood up to some diagnostic ‘fads’, especially as complex PTSD has been rejected time and again, unlike ICD which has included it seemingly for convenience, despite the incredible shakiness of the whole construct.
Thank you for this nuanced reply Paul! I think that's exactly it re DSM assess symptoms, and that seems to be enough. Particularly in the NHS that is exactly how we are trained, particularly as it's time efficient. Also very valid point that the DSM was never created to be used like this!! What would your ideal solution be do you think?
DSM is a product of the American Psychiatric Association, i.e. it is a diagnostic guide for psychiatrists. I tend to agree with Ghaemi that it should only include diagnoses that appear valid (e.g. by the Robins and Guze criteria) - although this task wouldn’t be so simple.
Outside of psychiatry, I can see utility of each psychological speciality having its own diagnostic manual. This is already the case in psychodynamic psychotherapy (i.e. ‘PDM’). Why can’t there be something similar for cognitive behavioural therapies, which could include things like social anxiety disorder, GAD, etc. Its purpose would not be to establish validity, but to facilitate communication and to guide both research and treatment selection.
Thanks for writing and sharing your comments. Thinking of workable solutions is very tricky. Historically, CBT aligned itself with psychiatry as an opportunity; they followed the funding. However, this needn't continue. CBT has a solid enough foundation and evidence base without the need to hitch itself to an unscientific system. For example, the core processes and procedures of CBT guide us well enough and psychology could take the lead on this. We needn't wait for psychiatry to tell us how.
I very much enjoyed this read. It’s great to see Ghaemi’s work becoming more widespread. His book on the history - and failings - of the biopsychosocial model is also an insightful read.
I have very mixed feelings about DSM. As a CBT therapist I have found the diagnoses incredibly useful in guiding treatment decisions. Regardless of whether social anxiety disorder or insomnia disorder are valid constructs, the treatments I select look very different for each (e.g. video feedback would not be helpful to the latter whilst sleep restriction would be unhelpful to the former).
I think there is nuance to Ghaemi’s argument, as he’s also very critical of the anti psychiatry movement who contest that no psychiatric diagnosis is valid. He would argue that some are - I think around a dozen or so - like schizophrenia, bipolar disorder, panic disorder, OCD, and PTSD (which he likens to a psychological injury).
He suggests DSM has also caused practitioners to focus on assessing for symptoms (via a checklist) to make a diagnosis, rather than looking for other diagnostic validators like genetics/family history, course of illness, and treatment response.
In fairness to the DSM, it was never intended to be reified in the way it has been. Indeed, in the introduction - which basically no one reads - it suggests that it should be used as a clinical tool, alongside clinical judgement. I think its use in America to bill insurance companies is partly responsible for this.
Finally, the DSM has at least stood up to some diagnostic ‘fads’, especially as complex PTSD has been rejected time and again, unlike ICD which has included it seemingly for convenience, despite the incredible shakiness of the whole construct.
Thank you for this nuanced reply Paul! I think that's exactly it re DSM assess symptoms, and that seems to be enough. Particularly in the NHS that is exactly how we are trained, particularly as it's time efficient. Also very valid point that the DSM was never created to be used like this!! What would your ideal solution be do you think?
Thank you for the reply.
DSM is a product of the American Psychiatric Association, i.e. it is a diagnostic guide for psychiatrists. I tend to agree with Ghaemi that it should only include diagnoses that appear valid (e.g. by the Robins and Guze criteria) - although this task wouldn’t be so simple.
Outside of psychiatry, I can see utility of each psychological speciality having its own diagnostic manual. This is already the case in psychodynamic psychotherapy (i.e. ‘PDM’). Why can’t there be something similar for cognitive behavioural therapies, which could include things like social anxiety disorder, GAD, etc. Its purpose would not be to establish validity, but to facilitate communication and to guide both research and treatment selection.
Thanks for writing and sharing your comments. Thinking of workable solutions is very tricky. Historically, CBT aligned itself with psychiatry as an opportunity; they followed the funding. However, this needn't continue. CBT has a solid enough foundation and evidence base without the need to hitch itself to an unscientific system. For example, the core processes and procedures of CBT guide us well enough and psychology could take the lead on this. We needn't wait for psychiatry to tell us how.