DSM-5: Searching For New Solutions

hoot, you’ve injured your arm! It was hurting for some time, and you think it may be broken — so you decide that you need to go to the hospital as you are having trouble navigating day-to-day life.

Once you get to the hospital, you have an interview with a doctor for an assessment of your symptoms and history of arm injury. You are asked a series of questions such as:

Have you felt pain in your arm lately? How does that affect you? Does your arm improve or get worse as the day goes on? On a scale of 1 to 10, if 10 was really, really hurting, where would you put yourself?

You try your best to answer these questions; however, you are having some trouble. You are not exactly sure where your pain is placed on the scale of 1 to 10, or if your arm feels worse or better as the day goes on.

You seek to do a physical examination to figure out if you have a broken arm. But, the only physical tests available are ones to rule out another medical cause for your arm being broken.

Finally, the doctor thinks about the problems you described and entertains a more specific series of arm diagnoses. Meanwhile, you are frustrated, tired, and in pain, as you are not getting answers as to why your arm is hurting.

Of course, if you hurt your arm, this would not be the way you would be diagnosed — you would get an X-ray or an MRI. But if you suspected you had depression or other mental illnesses, most hospitals would use the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), and follow a categorical approach based on qualitative questioning to diagnose you. Similar to the way your hypothetical arm injury was diagnosed.

What is the DSM-5?

The DSM-5 — also referred to as the “Psychiatry Bible” — is the handbook used by most healthcare professionals as the authoritative guide to diagnosing mental disorders.

The DSM-5 contains descriptions, symptoms, and other criteria for categorically diagnosing mental disorders. It also provides a common language for clinicians to communicate about mental illness with their patients.

Issues With DSM-5

One of the main issues with the DSM-5 is that it does not provide an understanding of the human mental process — the mind.

Also, it does not account for the importance of various symptoms as the descriptions of symptom criteria are overly broad. This means that patients diagnosed with the same disorder may have very dissimilar clinical presentations.

Furthermore, the DMS-5 classifies mental disorders as if they were distinct entities. Even though people diagnosed with different disorders often have various characteristics in common. Also, doctors sometimes do not assess the qualitative diagnostic criteria methodically, often lacking the time or incentives to do so.

4 Alternatives to The DSM-5

There are 4 viable alternatives to the DSM-5, each with their own tricky acronym and long name to remember — ICD, PDM, HiTOP, and RDoC.

1. International Classification of Diseases (ICD)

The ICD is the most popular and similar alternative to DSM-5. Likely because it is the keeper of the diagnostic codes used for tracking incidence and prevalence rates, as well as for health insurance compensation.

The main difference between the DSM-5 is that the ICD includes not just mental health diagnoses but all disease-related diagnoses. Also, they have different publishers. The ICD is published by the World Health Organization (WHO), and the DSM-5 is published by the American Psychiatric Association (APA).

2. Psychodynamic Diagnostic Manual (PDM)

The PDM makes an effort to be descriptive rather than theoretical. So, unlike other methods, it explicitly has a psychodynamic take on diagnostics and mostly lacks a theoretical basis approach.

The PDM was created to combat the concerns about the gradual diminishment in the professional discourse of in-depth, biopsychosocial case formulation and individual treatment planning.

However, critics of the PDM say it fails to provide clinicians the detailed information necessary to guide effective interventions.

3. Hierarchical Taxonomy of Psychopathology (HiTOP)

The HiTOP is a data-driven, hierarchically based alternative to traditional classifications that showcases psychopathology — the study of abnormal cognitions — as a set of dimensions organized into increasingly broad, transdiagnostic spectra.

HiTOP working model

In the HiTOP framework, patient psychopathology is no longer described in terms of categorical diagnoses. Rather, psychopathology is conceptualized along dimensions with differing levels of severity. The constructs higher in the chart above are broader and more general, whereas constructs lower in the chart are more specific.

HiTOP explicitly acknowledges the clinical reality that no clear divisions exist between most mental disorders and normality or, oftentimes, even between neighboring disorders.

Moreover, the concept of diagnosis is not a boolean value of either being present or absent. Rather it is considered to be a profile that emphasizes the patient’s symptom severity.

HiTOP may improve communication as the dimensional ratings convey more specific information by relaying symptom severity in addition to improving the reliability of a given diagnosis. In contrast, the DSM-5 and ICD approach typically provides a single evaluation with a diagnostic group including a wide range of severity.

However, there are some barriers for integrating HiTOP into practice. For example, HiTOP communicates clinical problems based on psychopathological profiles rather than categorical diagnoses. Thus, explaining the meaning of higher-level profiles can be more difficult and time-consuming than listing multiple diagnoses.

4. Research Domain Criteria (RDoC)

The RDoC is a research initiative attempting to build a diagnostic system from the ground up — one that uses biological markers to diagnose mental disorders.

This method of diagnosing is gaining popularity as the National Institute of Mental Health (NIMH) declared they would no longer fund research proposals that use DSM-5 diagnoses — instead requiring researchers to use the RDoC matrix.

The RDoC quantitative view of mental disorders — and the resulting diagnostic systems — provide benefits such as reliability and ease for diagnosis. However, for the RDoC to work, we need to understand a comprehensive picture of a typical and atypical brain and behavioral development across the lifespan.

Right now, research is not far enough along for RDoC’s adherents to construct a strictly biomarker-based diagnostic system. However, the RDoC hopes one day to replace the DSM-5.

How Can Alternatives To DSM-5 Change The World

A quantitative way of prescribing mental disorders can serve as a way of helping doctors make an accurate diagnosis — saving time and resources for both the patient and the doctor.

This approach would improve the DMS-5 system in place now, where mental illness is diagnosed via answers to qualitative questions that can mislead the doctor to make the wrong diagnosis. Plus, the quantitative data generated can be used to train AI algorithms to improve mental health.

Alastair Denniston, a doctor and honorary professor at the U.K.’s University of Birmingham argues that:

If anything, technology can help doctors focus on the human elements of medicine, rather than getting bogged down in the minutiae of diagnosis and data collection.

Rather than spending most of the time Doctors have with patients diagnosing if there is a breakthrough in quantitative approaches to mental disorders, they can focus on relaying treatment options for the illness.

Clearly, alternatives to the DSM-5, such as the ICD, PDM, HiTOP, and RDoC, may have the potential to make the world a more productive, happier, and healthier place!

I am passionate about health and technology especially when the two are used together to help others.