Beyond Diagnosis

"A disorder of mental life and behavior doesn't occur in a vacuum but is always embedded in the life of the patient."

-Margaret S. Chisolm, MD & Constantine G. Lyketsos, MD, MHS

An Evolving Framework

Framework

While my medical education and training focused on the bio-psycho-social model, my personal practice has evolved with experience.

The Biomedical Model

To understand the lens I practice psychiatry through, it's helpful to consider some historical context. The American healthcare system has been dominated by the biomedical model since the scientific revolution. Within this framework:

Illness is always seen as a physical, biological disease
'Health' is defined as the absence of any physical signs of disease

Impact on Psychiatry

This has led to the reductive conclusion that psychiatric disorders are brain diseases resulting from chemical imbalances. Consequently, these conditions are thought to be 'curable' with specific medications designed to 'correct' these imbalances. However, despite a significant rise in the use of psychiatric drugs since the 1950s, mental health outcomes continue to be poor.

The Bio-Psycho-Social View

In 1977, American psychiatrist George Engel proposed the "bio-psycho-social" model of medicine, asserting that the existing model was overly simplistic. He recognized that the biological, psychological, and social intersect and interact, influencing each person's health and susceptibility to illness. Today, this model continues to serve as the primary conceptual framework taught in medicine. Whether it is put into practice, however, depends on the physician.

Bolton, Derek and Gillett, Grant. The Biopsychosocial Model of Health and Disease: New Philosophical and Scientific Developments. Palgrave Pivot, 2019.

What are The Perspectives of Psychiatry?

This approach acknowledges the complexity of human beings, emphasizing that no single method can fully account for all psychiatric conditions. It encourages clinicians to look beyond the DSM and bio-psycho-social model, examining each patient from four distinct perspectives: disease, dimensional, behavior, and life story. This comprehensive understanding enables the development of a truly holistic and personalized treatment plan.

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Disease Perspective

What a Patient HAS
Treatment Goal: Cure

Represents the conventional viewpoint in western medicine
A pattern of signs and symptoms is classified as a syndrome
Syndromes arise from underlying pathology (the “broken part”)
Pathology is attributed to a specific etiology, such as infectious, immune, physical injury, etc.

Etiology
(E.g. Infectious, Metabolic, Genetic, etc.)

Pathological Process
("Broken Part")

Clinical Syndrome
(Signs & Symptoms)

Chisolm, Margaret S., and Constantine G. Lyketsos. Systematic Psychiatric Evaluation: A Step-by-Step Guide to Applying the Perspectives of Psychiatry. Johns Hopkins University Press, 2012.

What about the DSM?

In 1952, the American Psychiatric Association (APA) introduced the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Researchers needed a standardized way to group patients with similar symptoms for studies advancing psychiatric treatment. Since then, the manual has undergone significant revisions, with the latest version released in March 2022. Each diagnosis contained within is characterized by a set of clinical symptoms that have been agreed upon by APA committees. However, there is no denying that members of these groups, while highly educated, are also human with their own flaws and biases.

The DSM was intended to provide a shared language for describing the constellation of symptoms exhibited by patients, facilitating the process of diagnoses. However, having a shared vocabulary does not ensure that everyone interprets these terms in the same way. For instance, when someone says they "feel depressed," they could be alluding to a variety of underlying experiences. It is the clinician's responsibility to delve into the patient's experiences and contextualize them within the clinical criteria provided.

That said, it is important to acknowledge the valid criticisms directed at the DSM. For some conditions, research has shown clinicians frequently disagree on the diagnosis for the same patient. There are concerns that diagnostic criteria cast too wide a net, allowing nearly any behavior to be labeled as pathological. Over diagnosis in a system that lacks access to psychotherapy and social services, could contribute to excessive medication use. Some critics argue that a rigid adherence to the DSM may obscure the broader historical and social influences that shape individuals' lives.

American Psychiatric Association. (n.d.). DSM History. Psychiatry.org - DSM History. https://www.psychiatry.org/psychiatrists/practice/dsm/about-dsm/history-of-the-dsm

"It is good to know and use the DSM definitions, but not to reify or worship them."

-Allen Frances, MD (Saving Normal)

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