number of dsm diagnoses
I'd like to get something off my chest about the number of diagnoses in the various DSMs. First, though, let me say that I don't have definitive, final numbers. That'll have to await better research and more thought.
My thoughts were set in motion by yet another statement (this time, in Psychiatric Times for July 2013, by S. Nassir Ghaemi, MD, MPH). In an article titled "Requiem for DSM," he notes that the number of diagnoses has grown from about two dozen (the Research Diagnostic Criteria of Spitzer et al (Archives of General Psychiatry, 1978; 35:773) to 265 diagnoses (not including modifiers) in DSM-5 today. Dr. Ghaemi calls 90% of the current DSM diagnoses unscientific, and says that DSM-5 is "91.9% false, based on the original 2 dozen RDC criteria divided by 297 DSM-IV diagnoses." Well, there's a lot there to talk about, but I'll confine myself to one issue, plus Dr. Ghaemi's conclusion--of which, more in a moment.
Quite frankly, I am getting a little weary of the meme that we suffer from diagnostic inflation and of the numbers that are floated to demonstrate it. Of course, there are more diagnoses now than there were 35 years ago, but is that so surprising? We've identified a fair number of new disorders, after all, and we've found nuances that are important to the treatment of our patients. Science marches on.
It all hinges on how and what we count. Stated one way, I can come up with 600 discrete diagnoses in DSM-5. That includes every numbered mental health diagnosis DSM-5 mentiones in connection with the forthcoming ICD-10 scheme. But of course, by no means does every one of these represent a distinct disease process. Many are simply a matter of degree (mild versus major neurocognitive disorder, for example), and many more are different states of what must be fundamentally the same process (say, bipolar depression single episode versus bipolar recurrent depression). And those 600 don't even include all the possibilities when you add in myriad specifiers. If we did add them in, their permutations could extend the count into the tens of thousands.
When I carefully count up what I consider to be discrete diagnoses in DSM-5, I reach the high water mark of 155; the semi-official count by those who wrote the book is 157--close enough that I didn't feel impelled to go hunting for the discrepancy. My count includes, for example, separate entries for bipolar I disorder, bipolar II disorder, dysthymic disorder (which we now call persistent mood disorder), and major depressive disorder--but not additional entries for bipolar I manic, bipolar I depressed, bipolar I hypomanic, &c. There's a separate entry for cocaine use disorder (the new term for what DSM-IV called cocaine dependence) and for cocaine intoxication and for cocaine withdrawal. Though each of these is a symptom of the use disorder, it can be diagnosed as a free-standing condition. I've included "substance-induced psychotic disorder" but not separate entries for alcohol-induced or cocaine-induced psychotic disorders. Of course, well-meaning people can disagree as to how to divide this particular pie. I'll be glad to send along my complete list to anyone who is truly interested.
I'd be really happy to entertain other viewpoints about the total number we should be counting, but I think it's safe to say that 297 is a stretch, and that it is vastly overstating to say that DSM-5 is 91% false. On that issue, I truly beg to differ. This point of view claims that gender dysphoria is not a disorder, that anorexia nervosa is a fraud. Try telling that to the relatives of countless people who have died of that non-illness. There are any number of other disorders on the list that I'd claim are well-underpinned with experience and good research.
Further, the authors of the long-ago RDC criteria never intended that the number of acceptable diagnoses remain static, only that new disorders be based on studies that affirm reliability and, most importantly, validity. In large measure, the disorders included in DSM-5 do just that--though there are one or two exceptions that I reserve the right to discuss. Later.
It's Dr. Ghaemi's conclusion, however, that I find truly distressing. For he proposes to go his own way diagnostically, and by inference recommends that we all do the same, leaving "…clinicians free to use the best of what they know to diagnose, or not to diagnose, not because they are told to do so in a certain way by DSM, but in their best judgment of the art and science of psychiatry." This, of course, is the way to chaos, the same diagnostic anarchy that culminated, years ago, in a state of affairs in which American psychiatrists were wont, far more than their European counterparts, to lumber a psychotic patient with the diagnosis of "schizophrenia," disregarding symptoms that would lead many others to a finding of a mood disorder with psychosis. Whatever you think of the current DSM, the solution cannot be to disregard scientific research and rely on your instincts. No one's instinct is that good.
My thoughts were set in motion by yet another statement (this time, in Psychiatric Times for July 2013, by S. Nassir Ghaemi, MD, MPH). In an article titled "Requiem for DSM," he notes that the number of diagnoses has grown from about two dozen (the Research Diagnostic Criteria of Spitzer et al (Archives of General Psychiatry, 1978; 35:773) to 265 diagnoses (not including modifiers) in DSM-5 today. Dr. Ghaemi calls 90% of the current DSM diagnoses unscientific, and says that DSM-5 is "91.9% false, based on the original 2 dozen RDC criteria divided by 297 DSM-IV diagnoses." Well, there's a lot there to talk about, but I'll confine myself to one issue, plus Dr. Ghaemi's conclusion--of which, more in a moment.
Quite frankly, I am getting a little weary of the meme that we suffer from diagnostic inflation and of the numbers that are floated to demonstrate it. Of course, there are more diagnoses now than there were 35 years ago, but is that so surprising? We've identified a fair number of new disorders, after all, and we've found nuances that are important to the treatment of our patients. Science marches on.
It all hinges on how and what we count. Stated one way, I can come up with 600 discrete diagnoses in DSM-5. That includes every numbered mental health diagnosis DSM-5 mentiones in connection with the forthcoming ICD-10 scheme. But of course, by no means does every one of these represent a distinct disease process. Many are simply a matter of degree (mild versus major neurocognitive disorder, for example), and many more are different states of what must be fundamentally the same process (say, bipolar depression single episode versus bipolar recurrent depression). And those 600 don't even include all the possibilities when you add in myriad specifiers. If we did add them in, their permutations could extend the count into the tens of thousands.
When I carefully count up what I consider to be discrete diagnoses in DSM-5, I reach the high water mark of 155; the semi-official count by those who wrote the book is 157--close enough that I didn't feel impelled to go hunting for the discrepancy. My count includes, for example, separate entries for bipolar I disorder, bipolar II disorder, dysthymic disorder (which we now call persistent mood disorder), and major depressive disorder--but not additional entries for bipolar I manic, bipolar I depressed, bipolar I hypomanic, &c. There's a separate entry for cocaine use disorder (the new term for what DSM-IV called cocaine dependence) and for cocaine intoxication and for cocaine withdrawal. Though each of these is a symptom of the use disorder, it can be diagnosed as a free-standing condition. I've included "substance-induced psychotic disorder" but not separate entries for alcohol-induced or cocaine-induced psychotic disorders. Of course, well-meaning people can disagree as to how to divide this particular pie. I'll be glad to send along my complete list to anyone who is truly interested.
I'd be really happy to entertain other viewpoints about the total number we should be counting, but I think it's safe to say that 297 is a stretch, and that it is vastly overstating to say that DSM-5 is 91% false. On that issue, I truly beg to differ. This point of view claims that gender dysphoria is not a disorder, that anorexia nervosa is a fraud. Try telling that to the relatives of countless people who have died of that non-illness. There are any number of other disorders on the list that I'd claim are well-underpinned with experience and good research.
Further, the authors of the long-ago RDC criteria never intended that the number of acceptable diagnoses remain static, only that new disorders be based on studies that affirm reliability and, most importantly, validity. In large measure, the disorders included in DSM-5 do just that--though there are one or two exceptions that I reserve the right to discuss. Later.
It's Dr. Ghaemi's conclusion, however, that I find truly distressing. For he proposes to go his own way diagnostically, and by inference recommends that we all do the same, leaving "…clinicians free to use the best of what they know to diagnose, or not to diagnose, not because they are told to do so in a certain way by DSM, but in their best judgment of the art and science of psychiatry." This, of course, is the way to chaos, the same diagnostic anarchy that culminated, years ago, in a state of affairs in which American psychiatrists were wont, far more than their European counterparts, to lumber a psychotic patient with the diagnosis of "schizophrenia," disregarding symptoms that would lead many others to a finding of a mood disorder with psychosis. Whatever you think of the current DSM, the solution cannot be to disregard scientific research and rely on your instincts. No one's instinct is that good.