The controversy swirling around the creation of DSM-V reminds me of concerns that have troubled me since the advent of DSM-III. DSM-III represented a break with its 2 nosologic predecessors in its atheoretical stance and emphasis on defined observations. My mentor Gerald Klerman called it “Neokraepelinian.”
DSM-III could not create validity (something modern psychiatric nosology still waits for), but it did carry the promise of reliability. If applied as directed, DSM-III and its current successor, DSM-IV, should result in two clinicians making the same diagnosis in a patient. That brings me to my first concern: In real clinical life, DSM diagnoses often are applied casually—even sloppily. The required criteria are not met, and often a patient carries a slew of diagnoses that have been made by different psychiatrists—something that causes embarrassment for our field when it comes to public awareness.
My second concern is the loss of our field’s traditional “third ear.” Historically, psychiatrists listened not only to what a patient said, but to how the patient said it. Gaze, facial expression, tone of voice, body posture—all factored in to the clinician’s assessment and follow-up questions. I can’t count the number of psychiatric residents I’ve observed apply DSM-based questions in a clinical interview in a rote, checklist, fill-out-the-form manner, lacking warmth, empathy, and human intuition. Lyrics—but no music.
Let’s work to improve and enhance our diagnostic categories as we move forward to DSM-V. But let’s not lose the “baby” with the “bathwater.” After all, we are psychiatrists.