What we’ve said about DSM-5

“We should never forget that the DSM is not exactly a scientific document. We try to use science to inform it, but it's a product of professional consensus. It will change. It must change”

“before we had the DSM, you had a billion different theories, a billion different nosologies. Everyone was calling everything differently. Everyone thought they were right, and there was no way to communicate”

“DSM criteria is not a diagnostic test. It's not... they treat it that way especially the psychologists who build these instruments in these psychological tests okay that's not a test that is a description of a syndrome and it's the incomplete description of a syndrome”

“Any DSM diagnosis simply serves to capture one slice of a patient's presentation of pathology. This is also another problem with a lot of anti-psychiatry people”

“The DSM is looking at outputs. The DSM is looking at behaviors. It looks at things that are observable. And the big issue with that is that it's relatively agnostic as to what's going on underneath. So the benefit is that it's more objective because you're looking at observable qualities”

“the bipolar 1 and 2 categories in the DSM have been created to give an adequately reliable sample set and definition of a specific manic depressive type illness that can then be used for studies and research”

“These are all real known clinical types, but do they reflect the same underlying cause? Not necessarily”

“The DSM was never really meant to be a textbook of psychiatry or psychopathology. It actually didn't matter at all before DSM-3. No one really used it. It was really for research purposes”

“the way I think about it is I learn a lot about psychopathology and pathology, and then I cram it into the little boxes of the DSM. To me, that's the healthiest way to do it”

“You can see the limitation in using DSM diagnoses. Do not take diagnosis and use that to extrapolate to the facts. Take the facts and use that to extrapolate to a diagnosis”

“the story that the patient comes with, their chief complaint, why now? That stuff will lead you down the road to determine what you should even be asking about specifically”

“using the major DSM chapters, being aware of their names, use that as your major differential diagnosis. Don't drill down to a specific diagnosis within each chapter just yet. Simply think of the major category first”

“probably 90 of patients with genuine psychopathology are going to be capable of simply telling you DSM diagnostic criteria without you ever mentioning the DSM criteria, because that's their lived experience”

“if you get any positive screens, don't first go for the diagnostic criteria. That's confirmatory testing in my mind. OK, still get narrative”

“To me, I don't find it helpful at all with bipolar to walk through the specific DSM criteria. I just don't find it helpful. It is for a lot of conditions where you can walk through the symptoms exactly and then see what they say. For bipolar, I don't find it helpful”

“Despite the DSM explicitly telling legalists not to use it as a manual or Bible, the law basically treats the DSM as the Bible. of psychiatric conditions”

“I don't think the DSM is actually limited. I think people's understanding of the DSM is limited. They've probably never even read under other specified bipolar disorder where they talk about subthreshold hypomania”

“Don't restrict yourself to what is described in the DSM criteria alone. Read through all of the DSM and then read even more”

“You memorize the criteria to pass the exams and you assume that means you understand something. But the real learning is in the surrounding texts and in the formulations, not these checklists' criterias”

“If you take certain things in, let's say, the DSM at face value without understanding the history behind it, you're practicing almost cargo cult psychiatry”

“What percentage of you have gone to section three and read the alternative model for DSM personality disorders? And again, the general personality disorder text”

“Don't just stick to DSM. There's been so much written in this field for over 100 years that we really limit ourselves if we simply read the DSM in the latest edition of our favorite psychiatry textbook”

“If you actually learn people, they rarely fit into one. It's not like there's these 10 personality styles that everyone fits into. Now, the alternative model is a little bit better because it's more dimensional”

“I do miss the old axis one and axis two split. It was simplistic, but it pushed us to think about personality alongside symptoms. Today, like we, a lot of people just stop at depression or bipolar, whereas personality is going to run through all of it”

“studies actually show that for both inpatient and outpatient clinical populations in psychiatry. Most people can meet criteria for a DSM personality disorder. It doesn't mean that's the main issue going on”

“A big part of the definition of a personality disorder is that most personalities have some degree of adaptability, and personality disorders is a lack of flexibility with how they respond to their environment”

“What really organizes personality is something more like themes and stories. What's the primary narrative of the person, or what some of the cognitive folks call schemas”

“the most common kind of personality type that existed in the literature, including the empirical literature before 1980, was depressive personality. But people on the mood disorders task force didn't want to have depressive personality in there”

“whether or not something is biological or psychological has no bearing on whether it's a clinical problem or not. And we want to medicalize, clinicalize these problems in order to help people”

“you don't need anything more than two out of four of these schizophrenia criteria today to have schizophrenia. Only one of them has to be delusions or hallucinations or disorganized behavior or speech”

“a lot of people out there in the community have a habit of diagnosing post-traumatic stress disorder without actually going through the criteria. They kind of identify that someone is in a persistent fear or mood problem And that they have a criteria in a trauma and they say, well, they've got that”

“the diagnostic criteria for ADHD have become almost useless because if someone is motivated enough for any reason, unconsciously or inadvertently or just based on their understanding of what is or is not ADHD. If someone is motivated to answer an affirmative to structured interview questions”

“the second part, and this is the part that I think is the crux of OCD, is the individual attempts to ignore or suppress these thoughts, urges, or images and or neutralize them with some other thought or action”

“then dsm5 they realized that that didn't work and it's just fixed beliefs that are not amenable to change in light of conflicting evidence which isn't a particularly good definition”

“In DSM 3 and 4, PTSD and other related disorders and OCD were considered anxiety disorders. They are now considered separate chapters, and I actually agree with that separation”

“When DSM-3 was coming out in the 80s, there was a lot of concern. There were some studies showing psychopaths. And so, you know, a big concern was, you know, getting things down to reliability and checklists and emotions were felt to be unimaginable”

“There's so many patients where it's like, yeah, you're having problems. Let's call it generalized anxiety disorder, give you Zoloft. It kind of works. We're not really talking about the real problem, but we can both put our blinders on and pretend that it's just this categorical thing”

“You don't lower a fever and say, okay, problem solved. or cure a skin rash and not be interested in what it's telling you about what's going on in the body. And you can describe a limp in terms of present versus absent criteria, but you're not you're not saying that it is the disorder”

“it used to be people would come and they'd say to me something like, I'm very shy. I need help getting more comfortable around other people. I'm an introvert. And now they come and they say, I have social phobia. What do you think I should, what medicine should I be taking”

“I want to emphasize we're not anti-psychiatry here, we're psychiatrists. Some of these points can be used and abused by anti-psychiatry zealots in order to use a broad brush to cancel out the validity of everything”

“American psychiatrists were diagnosing schizophrenia basically twice as often as their British counterparts. A lot of what we would now call bipolar disorder and borderline personality disorder was being called schizophrenia at that time”

“there was a real division during the crafting or the development of DSM-3 between psychiatrists who wanted to prioritize validity and Versus psychiatrists who wanted to prioritize reliability”

“the Feiner paper listed 14 psychiatric disorders. The RDC, the Research Diagnostic Criteria published in 1978, a group led by Robert Spitzer, identified 25 psychiatric conditions. When DSM-3 is published in 1980, just two years after the RDC is published, that paper, it lists 265 distinct psychiatric diagnoses”

“Starting with DSM-3 and especially DSM-3R, which I think is published in 1988, it removes actually a lot of the hierarchy from DSM. So it becomes possible, for instance, to diagnose generalized anxiety disorder and major depressive disorder in the same patient. Now we can diagnose autism and ADHD in the same patient”

“when Alan took over DSM-IV, he said explicitly that he was going to have a very high bar to make any changes. It was going to be a very conservative document in the sense that the basic essence of DSM-IV was going to remain”