An interesting letter regarding DSM classifications.


I like your logic here and I agree with your conclusions. However, you penned this article on the assumption that psychiatric nosology is a validated classification, and that a diagnosis would be known to a psychiatrist if they could directly examine a patient. I think you well aware that the DSM classifications are motivated by a mix of attempting to avoid under or over diagnosing a condition, receiving reimbursement, compromising with special interest groups within psychiatry, and that the names of conditions change, merge, or split over the generations of new DSMs depending on a multitude of factors that have little to do with the validity of a condition. Most crucially, there are no biologically measurable anchor points to objectify the labels we give as diagnoses, there is considerable overlap between many criteria sets, and even the DSMs are clear that they do not purport to classify conditions based on etiology much less objective measures.

The conclusion of all this mess is that, even if a psychiatrist did evaluate a person directly, and even if it was ethical to discuss those findings, any discussion would need the disclaimer that diagnostic labels in psychiatry are for the working purpose of formulating treatment directionality, they are not proven entities that are tied to a clearly definable and objectively measurable parameter as for example leukemia, stroke, MI, etc. are, and thus it is probably unethical to even mention a differential diagnosis much less the name of a condition to anyone not involved in treatment planning, implementation, or support.

In psychiatry, all labels should be given with this caveat and cautions to patients. The results of treatment challenge and dechallenge and longitudinal course follow-up can help with some level of treatment confidence, but these are by no means validating our classification. It is probably prudent to leave any and all professional opinions out of the public realm on scientific if not ethical grounds. This conclusion has nothing to do with the fact that psychiatrists are also members of society allowed to give like/dislike or agree/disagree opinions about public figures, but not a diagnostic or other psychiatric label, both because of lack of validity as well as on ethical grounds.

Thank you for again writing on a timely topic.

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