Saul Marcus, ND - Naturopathic Doctor

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DSM Diagnosis

You may have heard that psychiatric diagnoses are diseases just like other diseases. This is simply not correct. This page explains how proper medical diagnoses are made and why psychiatric diagnoses do not describe real medical conditions.

How to make a proper medical diagnosis

Subjective Symptoms

In medicine something you feel is called subjective. By definition, anything your tell your doctor you have or feel is subjective.

Objective symptoms

Anything a doctor can see is called objective. This includes all findings on laboratory tests and physical exam. High blood pressure, cholesterol or a broken arm on a x-ray are objective findings. Objective findings are not open to interpretation.

Subjective Symptoms Objective symptoms
Subjective symptoms of the flu Medical checkup

Something the patient feels:

  • Chills (feels cold)
  • Sore throat (throat feels painful when patient swallows)
  • Muscle pain
  • Headache
  • Eyes feel irritation
  • Upset stomach
  • Fatigue

Something the doctor can see:

  • Fever (such as a oral temperature of 103°F)
  • Coughing
  • Eyes are water, or reddened
  • Red face and mouth
  • Increased white blood cell count on blood test

What is a medical diagnosis?

The doctor uses the subjective and objective information to form a diagnosis. The diagnosis is a term used to identify a specific illness.

For example, in order to diagnose a patient with diabetes, tests for objective markers such as blood sugar and HgA1C are run. To diagnose a patient with hypothyroidism, TSH, T3 and T4 are measured.

Although subjective symptoms are important in guiding the physician towards the diagnosis, ultimately the diagnosis is confirmed through objective signs.

What is a psychiatric diagnosis?

Psychiatric diagnoses are listed in the "Diagnostic and Statistical Manual," abbreviated as the "DSM." The fifth version of the DSM (DSM-V) was published in March, 2013, as an update to last version of the DSM-IV published in 2000.

To understand what goes into making a psychiatric diagnosis, lets take the example of Generalized Anxiety Disorder as defined in the DSM-IV.

A. Excessive anxiety and worry (apprehensive expectation), occurring more-days-than-not for at least 6 months, about a number of events or activities (such as work or school performance).
B. The person finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more-days-than-not for the past 6 months).

  1. restlessness or feeling keyed up or on edge
  2. being easily fatigued
  3. difficulty concentrating or mind going blank
  4. irritability
  5. muscle tension
  6. sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

D. The focus of the anxiety and worry is not confined to features of other Axis I disorder (such as social phobia, OCD, PTSD etc.)
E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism), and does not occur exclusively during a mood disorder, psychotic disorder, or a pervasive developmental disorder.

So what is Generalized Anxiety Disorder?

You will notice some problems with the definition of Generalized Anxiety Disorder:

So then what kind of diagnosis is Generalized Anxiety Disorder?

It may be OK to use this term as a description of symptoms, but it isn't a objective diagnosis. It's simply a description of the symptoms the patient has.

At first it may sound reasonable to treat according to description of mental symptoms, but upon closer examination it really does not. For example lets take the example of two people, both with Generalized Anxiety Disorder:

Do they both need the exact same treatment?
Man with anxiety due to a high stress job
Boy with anxiety due to hypoglycemia
Has anxiety and panic attacks due to high stress, triggering hypercortisolemia (high levels of the stress hormone cortisol). Has anxiety and panic attacks due to hypoglycemia (low blood sugar)

On the surface both patients seem to have the same condition. However, their similar symptoms have different causes.

This is why it's important to treat the patient, instead of treatment the surface symptoms they present with. However, DSM diagnoses typically don't go beyond description of surface symptoms.