07 July 2013

Pragmatism in using the DSM-5

Someone on a listserv I’m on asked what looked suspiciously like a simple question (paraphrasing):Even though the DSM-5 no longer incudes ‘general functioning’ in diagnoses, should I put it in my reports anyway?

I’ve been in very many debates in and around DSM-5 issues, and I started a quick response, but found myself attaching even this very discrete issue to my whole philosophy of how we do diagnosis. Apparently, the DSM-5 and the debates leading up to it have impacted my thinking more than I realized. Although usually an aspiring idealist, I find myself circling in on the role of pragmatism in diagnosis.

We still appear to retain a belief that science should serve as the final arbiter for what is/is-not a diagnosis and when. But the content of the DSM debates has not been about the science (both sides appear to have a very similar view of the actual content of the empirical literature), but about how to apply it and about the fears for potential misapplication. That is, the lion's share of debate has been: What would it mean for SVP if Diagnosis X were in the DSM? What would it mean for insurance reimbursements if Diagnosis Y were in the DSM? What would it mean for civil rights if people with Sexual Interest A were given a technical name? If I may expand that thought: I suspect that, mostly without being explicit about it, we have been forming our opinions based on the results we want to see and then working backwards to endorse diagnostic criteria that guarantee our arrival at those outcomes.

Rather than a DSM or ICD determining who is subject to SVP laws (and, therefore, further expanding the enormous bills), the legislators and their electorate should be deciding. Rather than a DSM or ICD determining what an insurance company will cover, the insurance company (or, in my hope, its regulators) should be deciding. (And I am sure there are people who believe that this should occur through a health insurance market.) Rather than a DSM or ICD deciding who receives what kind of extra time or other benefits during academic testing…

The pattern emerges quickly. Despite mentions of science, the DSM debates were largely a conglomerate of all the difficult public policy questions that legislators, the public, and more than one industry were unable or unwilling or make and take responsibility for. But rather than fault the legislators, insurance companies, and other interests for failing to come to any effective resolution to these problems, we outsourced responsibility to DSM committees and fault them for failing to solve those same problems. (For the record, I am not calling for blanket amnesty for DSM committee members; I disagree with many of the decisions and processes that were legitimately in their purview.)

At this point, what we have is a DSM that represents a series of compromises between multiple competing interests. Of course, it’s probably safe to say that all the DSMs and ICDs etc. have been such compromises, but the Internet and the relative transparency of the DSM5 have made more obvious what used to be more masked.

So, when somebody asks how to interpret thus-and-such from the new DSM, I cannot do what I used to (try to) do. Instead, I find myself returning more and more frequently to the thought that we cannot seek to understand the guiding principles used by the DSM and to answer ambiguities by following the principle(s) they did. There is no guiding principle behind a collection of compromises, editorial committees, and tweaking administrators. For better or for worse, I find myself left only with my pragmatism: If it is useful to the case to include the information that used to be included on Axis III even though we no longer have an Axis III, then by all means include it. (As long as one labels what one is doing and the basis for it, the reader can always decide to discount it.)

My main conclusion and caution: We just ought not make one of the pair of easy mistakes: writing reports as if we were more definite than we are, and reading diagnostic manuals as if they were.