5 Statements Every Mental Health Professional Must Know To Avoid Big Pitfalls

Avoid the pitfalls of the DSMAtul Gawande in his book “The Checklist Manifesto” talks about two types of errors. Errors of ignorance, which occur because we don’t know enough and errors of ineptitude, which occur because we make incorrect use of what we know.

The Diagnostic and Statistical Manual (DSM) in psychiatry is one such tool where one can succumb to the second error.
Did you know that the DSM actually has a cautionary statement at the start? Yes, it is called a cautionary statement for a reason, because without reading that, it is very easy to assume that all diagnoses in the DSM are valid entities and that people can easily be boxed into categories. That is equivalent to using a diagnostic test incorrectly, which of course leads to incorrect diagnoses and much worse, non-detection of pathology when it exists. Over my last 12 years of clinical practice, I have seen a phenomenal variability in presentations and causes in almost every psychiatric disorder and using the DSM without understanding the nuances and the limitations can lead a practitioner and his/her patient down a slippery slope. The brain is way too complex to categorise individuals into neat boxes. Have a read of the article I wrote on depression and bipolar disorder and you can see the endless variations to these disorders. So if you haven’t read the cautionary statement then here are 5 statements you must know.

1. “It is well recognised that this set of categorical diagnoses does not fully describe the full range of mental disorders that individuals experience and present to clinicians on a daily basis throughout the world”. (DSM-V)

2. “Clinicians may encounter individuals whose symptoms do not meet full criteria for a mental disorder but who demonstrate a clear need for treatment or care”. (DSM-V)

3. “In DSM-IV, there is no assumption that each category of a mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder. There is no assumption that all individuals described as having the same mental disorder are alike in all important ways”. (DSM-IV)

4. “The specific diagnostic criteria included in DSM-IV are meant to serve as guidelines to be informed by clinical judgement and are not meant to be used in a cookbook fashion”. (DSM-IV)

5. “It should be recognised that these (mental disorder and general medical condition: my insertion) are merely terms of convenience and should not be taken to imply that there is any fundamental distinction between mental disorders and general medical conditions”. (DSM-IV)

The limitation of the categorical approach makes it particularly important for mental health professionals to develop skills of case formulation. I hope knowing the 5 points above makes a difference to your practice, as it has to mine. Patients are human beings with complex biological, psychological and social factors impacting on their illness. Understand these factors and their lives, then develop a strategy; a label won’t solve the issue, a strategy will.
Mark Twain was right; “It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so”.

This article is written by Dr Sanil Rege. Sanil is a Consultant Psychiatrist in private practice on the Mornington Peninsula and co-founder of psychscene.com. You can follow him on Google+

3 Responses to "5 Statements Every Mental Health Professional Must Know To Avoid Big Pitfalls"

  1. kemp says:

    i am currently a psychology student and value this information. Guidelines are there to help diagnose and help with treatment / therapy?? would be based on the professionals observation of any symptoms, or events, language used and presented in communications between the patient / client and the therapist. What symptoms would a psychologist or other professional look for / or would stand out……………indicating a client may be suicidal. Does crashing a plane killing lots of people constitute in any way shape or form the characteristics, and behaviour of a suicidal person? If the answer is yes, the professional involved has a duty of care to report persons who displays any type of behaviour, or speak of carrying out behaviour consequently harming themselves or other people. statutory guidelines. If the answer is no, what other possible explanations are their? FRUSTRATED………….the systems in place to protect either fail or made to look like they fail.

  2. kemp says:

    depression / mental illness should not be the scapegoat of these tragic events. These allegations negatively stigmatise those having suffered / or suffering with mental illness and provides yet another reason for them to be excluded from society. Those suffering from mental illness such as depression and anxiety as well as others will be further ostracised from society.

    • You raise some important and complex issues. Events such as suicide and homicide are rare issues. This makes prediction very very difficult from a statistical point of view. There is no test in psychiatry or for that matter in medicine that can predict something with 100% sensitivity (pick up true positives) or specificity (exclude true negatives) and when it comes to prediction of rare events the positive predictive value of these tests (i.e what is the possibility of the disease or event if the person tests positive on the test), is even lower in a rare disease or event , so low that it is often in the single digits. This makes prediction almost impossible. For example in the real world, one may ask about suicidal ideation, but does a yes or no answer predict behaviour? Several variables will play a part over the next several days, hours, weeks or years which will have a cumulative effect on the final behaviour.

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